May 2016 – Issue 6 ISSN 2050-3733

NUTRITION EXCHANGE
ENN
English
Contents
3 Editorial
4 Global and General Nutrition Themes
4 Global Nutrition Report
5 Nutrition Cluster Advocacy

WFP/Kiyori Ueno
5 en-net
6 Global Panel statement on climate change,
food systems and nutrition
7 Governance and Coordination
7 Evidence Informed Decision-Making Process
on Nutrition in Ethiopia
9 Innovative regional approaches to improving
Nutrition in Emergency (NiE) preparedness
and response capacity from Latin America and
the Caribbean (LAC)
A school meals programme in Ethiopia
What is Nutrition Exchange?
Nutrition Exchange is an ENN publication that contains short, easy-
to-read articles on nutrition programme experiences and learning,
from countries with a high burden of malnutrition and those that
are prone to crisis. Articles written by national actors are prioritized
for publication. It also summarises research and provides
information on guidance, tools and upcoming trainings in nutrition
and related sectors. It is available in English, French, Arabic and
Spanish.

11 Nutrition sensitive programming How often is it produced?

Nutrition Exchange is a free annual publication available as a hard
11 Nutrition in Mountain Agro-ecosystems copy and electronically.
12 Promoting good dietary practices in the
Democratic Republic of Congo How to subscribe or submit an article
To subscribe to Nutrition Exchange visit
14 Keyhole gardens in Ethiopia http://www.ennonline.net/nex
15 Briefing on the Bihar Child Support To contact the editors with feedback or about writing an article,
Programme, India email nutritionexchange@ennonline.net

16 The growing interest in Nutrition and WASH About the ENN

17 The nutrition-sensitive potential: Lessons The ENN enables nutrition networking and learning to build the
evidence base for nutrition programming. Our focus is on
from Haiti
communities in crisis and where undernutrition is a chronic
18 Nutrition specific programming problem. Our work is guided by what practitioners need to work
effectively.
18 Perceptions of severe acute malnutrition and • We capture and exchange experiences of practitioners
its management in Bangladesh through our publications and online forum En-net
• We undertake research and reviews where evidence is weak
19 Providing sustainable management of acute • We broker technical discussion where agreement is lacking
malnutrition services in Democratic Republic • We support global level leadership and stewardship in nutrition.
of the Congo
20 Niger Nutrition Alliance
22 Mobile clinics in Chad
24 Improving nutrition behaviours in Somalia
26 Scaling Up Nutrition
26 The Scaling Up Nutrition (SUN) Movement
Strategy and Roadmap (2016-2020)
27 ENN’s Knowledge Management Project ENN would like to acknowledge our translators and technical
28 Understanding the CRF and lessons learned reviewers Anna Kriz and Elise Becart, Randa el Ozeir and Soha
from five SUN countries Moussa, for the development of the French and Arabic versions of
this publication and Translators Without Borders.
29 Interview with the Dr. Hjordis Ogendo
31 Interview with Dr Mohamed Abdi Farrah Front cover: Gorkha district, Nepal, 2015, ©WFP/James Giambrone
Back cover: Peruvian peasant women in Cajamarca, ©WFP/Photolibrary
33 Role of communication and advocacy in
scaling up nutrition in Zambia This edition of Nutrition Exchange was funded by Irish Aid and through a
USAID/OFDA Grant to the ENN entitled 'Building international and national
34 SUN Experiences: Lessons from Pakistan sectoral and individual knowledge and capacity to respond to emergencies
34 SUN Movement experiences in Indonesia in the food security and nutrition sectors worldwide' under Agreement No.
AID-OFDA-G-11-00217
35 Nutrition advocacy in Kenya’s newly devolved
government system
38 News and events

2

Editorial
is issue of Nutrition Exchange is our sixth and we continue to
profile the writing of those working at national and sub-national
level. is issue contains 13 original articles from Bangladesh,
Chad, Democratic Republic of Congo, Ethiopia, Kenya, Niger and
Somalia and two with a regional and geographical perspective.
For the first time, we received French articles from west Africa
and have translated them into English for this issue. Every original
article is the result of a close supportive collaboration with the
author(s). ENN provides editorial support to get the best
information possible from those working on different types of
nutrition-related programmes and issues in different contexts.
ere is a stronger focus in this issue of NEX on learning and
experiences from Scaling Up Nutrition (SUN) Movement
countries. We have carried out two interviews with key SUN
Movement actors in Kenya and Somalia. In Kenya, the interview
with an outgoing representative of the SUN Donor Network
describes the experience of starting the network, their
achievements and future priorities. In Somalia, the Government
SUN Focal Point shared the challenges faced in bringing
nutrition to the wider attention of key government actors and in
maintaining this focus in light of the frequent disruption caused
by conflict and insecurity. e role of the SUN Civil Society
Network in supporting nutrition advocacy and, in particular, the
ongoing work to support nutrition in a highly devolved context is
described in Kenya. We also have a summary of the phase two
SUN Movement Roadmap, the findings from a recent review into
SUN country experiences with the Common Results Framework,
and a brief description of a new ENN project providing
knowledge management services to the SUN Movement in phase
two (2016-2020). Two summarised Field Exchange SUN-related
articles have been included in this section from Pakistan and
Indonesia as they describe the progress made since joining the
SUN Movement, highlighting the increasing need to focus on
nutrition scale-up in highly devolving situations and to continue
to foster multi-sectoral engagement at all levels. e double
burden of malnutrition (where high levels of undernutrition and
overweight/obesity are both present in a country) is also raised in
the Indonesia article.
e original country article from Bangladesh describes ongoing
work in the management of malnutrition in infants under six
months of age. For many years these infants have been a neglected
group, but today they are receiving more attention globally and in
certain countries. ree articles from west Africa (Niger,
Democratic Republic of Congo and Chad) give us insights into
efforts to address contexts with high levels of acute malnutrition.
In Niger, an alliance of non-governmental agencies is looking to
more sustainable/developmental ways to maintain treatment
services; in Chad, mobile teams are being deployed to reach
remote populations in need to treatment services; and in DRC the
challenges of maintaining effective, community-based nutrition
activities once they are mainstreamed into health service provision
with lower budgets are exposed. All these articles highlight the
practical challenges of applying the technical advances that have
been made to prevent and treat acute malnutrition. Additional
articles from DRC and Ethiopia describe the use of different
agriculturally focused activities to increase dietary diversity in
food-insecure areas. Keyhole gardens are one technology being
used in Ethiopia to support year-round food availability in food-
insecure regions, while the education system is being used in DRC
to promote dietary diversity and income-generation at household
level. In Somalia, behaviour change and communication (BCC) is
an approach being used to increase hand-washing and promote
NUTRITION EXCHANGE
improved infant and young child feeding to prevent
undernutrition. ese articles describe a range of nutrition specific
and nutrition-sensitive approaches. While most of the articles
describe relatively small-scale projects, it is encouraging to see
attention being given by some to measuring impacts: this is key if
decisions are to be taken for replication or scale-up.
We feature an article (IFOAM) describing an approach to
agriculture and nutrition in a number of countries with large
populations living in remote, mountainous regions. is is being
done by networking people through different platforms to access
better evidence and knowledge about nutrition-sensitive
agriculture and dietary diversity. In Ethiopia, the need to link
research more explicitly in order to evidence policies and
programmes is described, along with the way current obstacles to
this are being addressed. For the first time, we include an article
from the Americas, highlighting how the Latin America and
Caribbean Nutrition Clusters are working together regionally
and are using a tool for the standardised definition and
monitoring of regional and national nutrition preparedness and
response capacity in a context with recurring natural disasters.
As with previous issues, we have also included summaries of
nutrition-related reviews, research, events and global
developments that we hope are of interest to our readers. In
particular, we have summarised the latest developments in the
growing attention on the benefits of linking water, sanitation and
hygiene (WASH) with nutrition.
In mid-2016, the third Global Nutrition Report will be published
and we have included a summary (written by the coordinating
team) of the focus this will take. Along with the recently
announced Decade for Nutrition (also summarised), the
forthcoming Nutrition for Growth Summit in Brazil and the
launch of the new Sustainable Development Goals (see the
summary), nutrition is still receiving the attention it deserves
globally and, more importantly, across many countries where a
wide array of policies and programmes is being shaped and
implemented and which the NEX team is dedicated to trying to
capture and share for the benefit of country actors.
We warmly thank all those who have contributed articles and news
pieces and who have been available for interview for this issue. We
are already looking for new content for Issue 7 and encourage
anyone with experiences and learning to share about nutrition-
specific programming, nutrition-sensitive programming, nutrition
governance, coordination and financing to get in touch with us. In
keeping with our efforts to reach as many readers as possible, this
year we will be publishing NEX in Spanish (so copy only), thanks
to the UNICEF Regional Office in Panama and the financial
support from USAID and DFID as well as our usual French and
Arabic versions.
We warmly thank Valerie Gatchell for her early editorial role
before handing over to Jacqueline Frize, who has capably stepped
in to support the production of this issue while Valerie is away
from ENN. We also thank Chloe for doing so much before taking
her maternity leave. We appreciate the considerable support from
Gwenola Deplats in supporting the French-speaking authors in
west Africa and for adding to our French network and warmly
thank Nick Mickshik for copy editing.
e Nutrition Exchange Editorial team,
Carmel, Valerie, Chloe and Jacqueline
3
Global and General Nutrition Themes
2016 Global Nutrition Report
From Promise to Impact:
Ending Malnutrition by 2030
By Lawrence Haddad, Corinna Hawkes and Emorn Udomkesmalee,
Global Nutrition Report Independent Expert Group Co-Chairs
E
nding malnutrition by 2030 is a lot to ask, but the
ground has never been more fertile for a step
change in the level of commitment to high-impact
actions for nutrition improvement. Momentum
around nutrition has been building over the last decade, and
the inclusion of a commitment to “ending all forms of
malnutrition” in the UN Sustainable Development Goals
(SDGs) challenged the world to think and act very differently
on malnutrition: to focus on all its aspects and try to end it –
for all people – by 2030. 2016 brings major opportunities to
translate this commitment into action, with the adoption of
SDG targets at country level, the Nutrition for Growth (N4G)
process, and with Japan’s growing leadership on nutrition as
part of its G20 leadership and in advance of the 2020 N4G
summit.
In light of these opportunities, this year’s Global Nutrition
Report (GNR) – the third in the series – focuses on the theme
of making and measuring SMART (specific, measurable,
achievable, relevant and time-bound) commitments to
nutrition, and what it will take to end malnutrition in all its
forms by 2030. The report aims to make it easier for
governments and other stakeholders to make high-impact
commitments to ending malnutrition in all its forms. Equally
4 NUTRITION EXCHANGE
importantly, the 2016 GNR aims to make it harder for
stakeholders to avoid making such commitments.
At the same time, the 2016 GNR outlines how business-as-
usual is a recipe for failure: every country is facing a serious
public health challenge from malnutrition, with diet the
number one factor in the global disease burden. With
business-as-usual, we would reach global nutrition goals by
the late 21st century, if at all. Ending malnutrition is
ultimately a political choice: nowhere is this clearer than by
comparing the different nutrition choices that otherwise
similar countries make.
This year’s report has a particularly strong focus on
malnutrition in all its forms, including overweight, obesity
and nutrition-related, non-communicable diseases. It also
underlines the need to consider all forms of malnutrition in
country-level planning and measurement, as many countries
face the challenge of multiple forms of malnutrition.
The 2016 GNR offers guidance to governments and other
stakeholders on:
• Why commitments matter: they are a signal of intent;
they can provide a direction of travel for everyone; and
they seem to go hand-in-hand with improved
performance.
• Where to make commitments: which geographical areas
and which sectors.
• Who the commitments are being made for: which age,
gender and socioeconomic groups.
• How SMART, ambitious and aligned some of our current
commitments are, and how all our commitments to
nutrition could be more so.
• What kinds of commitments to make: which policies and
programmes to commit to and what level of funding is
available and required; and
• Who needs to do what and by when.
The Global Nutrition Report will launch on 14 June 2016 in a
number of locations (including Washington DC, Sweden and
Kenya). If you would like to get involved or follow what’s
happening, please follow us on @GNReport on twitter, or
contact josephinelofthouse@me.com
The Global Nutrition Report is an independent and
comprehensive annual review of the state of the world’s
nutrition. It is a multi-partner initiative that holds a mirror up
to progress on meeting inter-governmental nutrition targets.
It documents progress on commitments made on the global
stage and makes recommendations for actions to accelerate
progress . You can find out more and see our very useful
country nutrition profiles at http://globalnutritionreport.org

Article summaries
The Nutrition Cluster Advocacy
Strategic Framework
A
dvocacy as a cluster core function was included
in the Nutrition Cluster Strategic Plan 2014-
2016 for the first time. The new Nutrition
Cluster Advocacy Strategic Framework 2016-
2019 provides overall strategic direction and focus for
Nutrition Cluster advocacy efforts to ensure linkages
across global and country levels and cluster partners. The
strategy aims to help towards the development of
common messages and activities to leverage impact.
Three Advocacy Goal areas have been identified through an
extensive consultative process with cluster partners. They
identify outcome statements for an enhanced response to
the nutritional needs of emergency affected populations.
Each Advocacy Goal area is supported by Objectives,
Results and Indicators specifying the changes required to
contribute to the achievement of the Goal. For each result,
the Framework assesses the current external context and
barriers to be addressed, opportunities ahead for
influencing, and the Nutrition Cluster role.
Three types of Indicators to support the monitoring and
evaluation of cluster advocacy are proposed: Indicators of
The online forum for country actors who
need help and support with technical,
policy, research or governance related
nutrition questions
E
n-net is a free and open online resource run by the
ENN for anyone working anywhere in the world
who needs access to prompt technical support
and advice. It is available in English and French.
A quick online registration process allows en-net users to
post questions on any nutrition-specific or nutrition-
sensitive topic. Questions are received by an ENN
moderator, who directs the user to the appropriate
resource/en-net exchange if the answer to the question is
already available. If the question is not already covered, it
is posted for all en-net users to view and to respond. This
creates a thread of discussion and fosters peer-to peer-
exchange. If the query cannot be answered by
peer-to-peer interaction, the ENN moderator requests
specialist technical input from other specialists.
En-net currently covers 18 thematic areas. Recent en-net
discussion threads have included questions from
practitioners on the following:
• How to design programmes to overcome stunting in
NUTRITION EXCHANGE
Global and General Nutrition Themes
policy change; Indicators of significant
steps towards policy/practice change;
and progress Indicators.
nutritioncluster.net/advocacy/nutritioncluster.net/wp-
content/uploads/sites/4/2016/02/Nutrition-Cluster-Final-
Advocacy-Framework-v2.pdf
e three Advocacy Goals
Goal 1 Humanitarian response is well coordinated, aligned
and integrated for an effective, timely and quality
nutrition response to address the nutritional needs of
emergency-affected populations.
Goal 2 Sufficient resources are mobilised for an effective,
timely and quality nutrition response to address the
nutritional needs of emergency-affected populations
Goal 3 Appropriate preparedness, response and recovery
strategies are included as part of the global and
nutrition agendas to safeguard the nutritional needs
of emergency-affected populations
Afghanistan;
• The use of dietary diversity food categories to classify
the diet on households in Latin America;
• How to design a comprehensive database for nutrition,
water, sanitation and hygiene-promotion and food
security and livelihoods in Pakistan; and
• Guidance request for diabetes in different age groups.
Follow and join the discussions here: www.en-net.org or
for French www.fr.en-net.org
New: The SUN Movement en-net discussion
forum
The SUN Movement en-net is a new, free and open
resource to provide a space for informal discussions of
topical issues, approaches and good practices in relation
to SUN Movement country needs.
Fast online registration allows users to post questions on
any SUN-related topic. Anyone can create an account and
join in the conversation by posting questions to peers and
5
Global and General Nutrition Themes
responding to questions posted by others. Users can also
sign up to see the exchanges taking place on the site
between other forum participants. All questions are good
questions and there is no wrong question!
SUN en-net is primarily a peer-to-peer discussion forum and
also facilitates specialist input from experts in certain areas
who are able to address more complex questions. Any SUN-
related question can be posted at the press of a button. In
addition to the discussion forum, there are three thematic
SUN en-net areas:
1. Policy and budget-cycle management, from planning
to accounting for results;
2. Effective social mobilisation, advocacy and
communication; and
1
Global Panel statement on
climate change, food systems
and nutrition
“The Global Panel on Agriculture, Food Systems and Nutrition strongly believes that urgent policy action is
needed to tackle the challenges that climate change poses to agriculture, nutrition, and human health.”
E
vidence shows that changing climate conditions will
have important impacts on agricultural production
and the quality of food and nutrition available to
billions of people. In October 2015, the Global Panel
released a brief entitled Climate Smart Food Systems for
Enhanced Nutrition.
The Statement
• The Global Panel on Agriculture and Food Systems for
Nutrition is concerned that in the past agriculture has
not been afforded the priority that it deserves. Realising
nutrition outcomes from effective climate smart
agriculture will be essential for seeing progress towards
the implementation of the Sustainable Development
Goals (SDGs).
• Climate change is expected to push down global farm
output by 2% per decade between now and 2050.
Demand for food is expected to rise substantially
during that same period. All of us depend on the
nutritious food produced by millions of farmers for our
health and wellbeing. We will continue to do so even as
drought, extreme weather conditions and temperature
changes associated with climate change challenge the
resilience of the agricultural sector.
• Good nutrition is a universal goal that lies at the heart
of actions to resolve both undernutrition and diet-
related chronic diseases. These complex nutrition
challenges pose a huge burden for social and economic
development. Countries whose agriculture is likely to
be most negatively impacted by climate change are
those that already have the highest burdens of
undernutrition. Many of these countries are in Africa;
the impacts of climate change are therefore likely to be
highly significant for the continent.
6 NUTRITION EXCHANGE
3. Functional capacities for coordinated and effective
scaling-up of nutrition in action.
SUN en-net Discussions so far have included:
• The use of information and evidence in policy-making for
nutrition;
• What is the experience of SUN Movement networks in
advocacy to governments to create specific budget lines
for nutrition programmes?
• How can multiple government sectors become engaged
in planning and costing national nutrition efforts?
• How can parliamentarians be mobilised to help achieve
national nutrition objectives?
Follow and join the discussions here: www.en-net.org/sun
• Action to reduce agriculture’s contribution to
greenhouse gas (GHG) emissions is also imperative. The
Panel welcomes country submissions of their Intended
Nationally Determined Contributions (INDCs).
• Of the 156 parties that have submitted INDCs, only 24
refer to nutrition and fewer note the complementarity of
nutrition policies and climate action.
The Global Panel make the following policy
recommendations:
1. Include diet quality goals with adaptation targets
proposed for climate action.
2. Diversify agricultural investments, factoring in the local
realities of ecological sustainability and comparative
advantage.
3. Support greater food-system efficiency so that outputs
per unit of water, energy, land and other inputs are
optimised and the footprint of agriculture and non-farm
activities are better managed to meet both food demand
and higher-quality diets.
4. Integrate measures to improve climate change resilience
and the nutritional value of crop and livestock products
along the value chain, from production to marketing.
5. Protect the diet quality of the poor in the face of supply
shocks and growing food demand through social
protection, for example.
6. Promote the generation and use of rigorous evidence on
appropriate investments along food value chains which
are resilient to climate change and deliver positive dietary
outcomes and support improved nutrition.
www.glopan.org/news/climate-change-statement
1 The Global Panel is an independent group of influential experts with a
commitment to tackling global challenges in food and nutrition security.
 Governance and Coordination

Original article

WFP/Michael Tewelde
Women with children walking to Bella health post, Amhara region, Ethiopia

Evidence Informed Decision-Making

Process on Nutrition in Ethiopia
Tesfaye Hailu has an MSc in Human Nutrition. He has worked
for the Ethiopian Public Health Institute (EPHI)1 for the last eight
years as a researcher. He is also a member of the Scientific and
Ethical Review Committee of the EPHI.

Knowledge gained through research can help to improve policies, programmes and
practices within a nutrition service delivery system and can contribute towards significant
improvements in the nutritional status and nutrition equity of a country and beyond.

Coordinating mechanism While these committees function at a national level, there

The government high level National Nutrition
Coordination Body (NNCB) is the primary mechanism for
leadership, policy decisions and the coordination of
Ethiopia’s National Nutrition Programme (NNP). The
implementation of this programme began in 2008, using a
multi-sector and life-cycle approach. The NNP’s five-year
plan was revised in line with the Millennium Development
Goals (MDGs) for the years 2013-2015. The MDGs were also
used for the development of the country’s second five-year
NNP (2016-2020).
The NNCB includes government sectors, partners, civil
society organisations, academia and the private sector.
Under this body is the National Nutrition Technical
Committee (NNTC), comprised of senior nutrition experts
from the same sectors. This committee is divided into three
sub-committees:
• Nutrition Programme Coordination Sub-Committee
chaired by the Federal Ministry of Health (FMOH);
• Nutrition Research, Monitoring and Evaluation Sub-
Committee chaired by the EPHI; and
• Food Fortification Programme Sub-Committee chaired
by the Federal Ministry of Industry.
are other, similar, multi-sector nutrition coordination
programme implementation arrangements in place at
regional, district (woreda) and ward (kebele) levels, using
the decentralised structure. The terms of reference,
membership, frequency of meetings and roles and
responsibilities of sectors are detailed to ensure
transparency in conduct.
Generating appropriate evidence to inform
national policies and programmes
The Nutrition Research, Monitoring and Evaluation Sub-
Committee is led and coordinated by EPHI. Members of
the Sub-Committee access the research agenda of EPHI
and generate, translate and deliver evidence to decision-
makers to answer their policy and programme questions.
For example, Ethiopia is currently planning a national food
fortification programme; in order to ensure appropriate
fortification, decision-makers assessed the existing
evidence summarized by EPHI and invested in novel,
context-specific research. The latter entailed a National
1
Masresha Tessema and Yibeltal Assefa and Dr Ferew Lema at the Federal
Ministry of Health, Ethiopia have contributed to this article.

NUTRITION EXCHANGE 7
Governance and Coordination
National Nutrition Coordinating Body (NNCB)
Nutrition Programme
Coordinating sub-
A Terracing project allows farmers committee
to successfully continue cultivating Chaired-FMOH
the land on the hillside, Ethiopia
WFP/Giulio d'Adamo
Food Consumption Survey and a National Micronutrient
Survey which collected data on Ethiopian food intake and
micronutrient status, respectively. EPHI is also reviewing
existing data, including recently published systematic
reviews, to produce policy briefs on the relevance of zinc
fortification to Ethiopia. Furthermore, EPHI conducted the
National Nutrition Survey in 2015. The results of this survey
were reported to the FMOH to help set targets for the NNP of
2016-2020.
Information dissemination
While nutrition academics from EPHI are mandated to inform
nutrition actions, various other academic institutions have
also linked with the EPHI’s Department of Food Science and
the Nutrition Research Directorate specifically to provide
evidence-based answers to questions on nutrition
programmes from decision-makers. Evidence produced by
these institutions is shared across academia through annual
conferences and is subsequently compiled and presented to
appropriate government ministers to aid programme reform.
A website is also used to disseminate research outputs.
Main barriers identified so far and suggested ways
forward
Despite the ongoing efforts to use evidence in making
decisions about nutrition programmes, there are still a
number of gaps and barriers to the process of decision-
making in Ethiopia. These currently include:
• Poor use and integration of research outputs in
programme and policy changes;
• Insufficient personnel trained to work on producing
systematic reviews to inform policy;
women waiting at a health post, Ethiopia
WFP/Giulio d'Adamo
8 NUTRITION EXCHANGE
NNTC
Nutrition Research, Food fortification
monitoring and evaluation programme
sub-committee (evidence sub-committee
synthesis) Chaired-EPHI Chaired-Mol
• Poor use of health economics evaluation papers;
• High attrition rates of trained nutritionists in government
sectors;
• Difficulties in finding synergies between the agendas of
different development partners; and
• Poor linkages with the sub-national (regional) level.
Some of these barriers can be addressed through the
following:
• Short and long-term training of personnel in performing
systematic reviews and full health technology
assessments;
• Developing methodological tools and processes for
identifying and setting priorities in nutrition with
decision-makers;
• Establishing a national nutrition database of previous and
ongoing research and programmes performed within
Ethiopia by the different entities (NGOs, donors,
universities, EPHI, etc.); and
• Evaluating the systematic process of decision-making,
from priority-setting to the implementation of evidence-
informed policy briefs.
Thus far, Ethiopia has mapped the stakeholders involved in
evidence-informed decision-making in nutrition, identified
priority research topics by talking to these decision-makers
and various other key stakeholders, and built the capacity of
some researchers in nutrition academia on evidence
synthesis. The government has also recognised the
importance of evidence in policy-making. Many of these
actions have taken place due to Ethiopia joining the EVIDENT
Network (Evidence-informed Decision-making in Health and
Nutrition; see www.evident-network.org), The network is
facilitating Ethiopia in bridging the gap between science and
policy and has therefore become an integral part of EPHI’s
nutrition research agenda and the next five-year NNP.
In addition, Ethiopia’s experiences with the SURE
collaboration (Supporting the Use of Research Evidence; see
www.who.int/evidence/sure/guides/en) and its readiness to
accept evidence for better implementation of programmes
to improve the nutrition outcomes of the country will be
pursued to help overcome some of the barriers to evidence-
based policy and decision-making.
Finally, a key lesson learnt so far is that it is essential to have a
good governance structure in a country in order to facilitate
the acceptance of evidence-based policies and the concept
of evidence-informed decision-making and what it entails.
 Governance and Coordination

Original article Girl drinking water at Nuevo

Terminal Terrestre shelter

Innovative regional
approaches to improving
Nutrition in Emergency
(NiE) preparedness and

© UNICEF/ECU/2016-546/Castellanos
response capacity from
Latin America and the
Caribbean (LAC)
By Stefano Fedele, Regional Nutrition Specialist and
Rebecca Olson, NiE Consultant at UNICEF LAC Regional Office

Nutrition hazards, risks, vulnerability and
capacity in LAC
Improving preparedness and response capacity for NiE in
Latin America and the Caribbean (LAC) is a challenging
task. LAC has the highest urbanisation rate in the
developing world, with 79% of the population living in
cities. After Asia, it is also the region with the highest
number of natural disasters, predominantly occurring
during the hurricane season between May and November.
Floods and storms are related to almost 70% of the
disasters recorded. In absolute numbers, flood-related
disasters have quadrupled in the past decade and storm-
related disasters have increased five-fold. Drought-related
disasters are also rising, with three and a half times as
many in the past decade compared to the 1970s.
The risk of being affected by natural disasters is
compounded by the level of the hazard and the degree of
vulnerability. In the Caribbean region, with its diverse
island states and annual tropical storms, there is a wide
range of risk levels. In Haiti, low human development and
severe environmental degradation cause far more damage
compared to other Caribbean states, despite similar levels
of exposure.
In recent decades, LAC has made significant strides in
understanding and improving policies for disaster
management, early warning systems and organisation of
emergency response. If the 230,000 estimated deaths due
to the Haiti earthquake and the recent Ecuador
earthquake in which nearly 700 lost their lives are
excluded, overall, fewer people die from natural hazards in
the region today than a decade ago. Mexico, Chile,
Colombia and Costa Rica are among the countries in the
region that have improved their capabilities to predict
some risks, as well as prepare for and manage
emergencies. Moreover, although the capacity to ensure
food assistance at times of emergency has increased, the
prioritisation of nutrition as a programme area at times of
disaster and the capacity to ensure adequate nutrition
specific preparedness and response is not the same across
the region.
Floods and droughts in LAC are expected to increase in
frequency, intensity and unpredictability in the future.
Providing safety nets and protecting communities present
an increasingly difficult challenge for governments in the
region. The least developed sub-national areas which are
currently enduring higher rates of child stunting and
inequity are also likely to be the most affected by climate
change and consequent reduction in yields of subsistence
crops, cash crops, soil and forest productivity and reduced
livestock production. Infectious disease rates are also likely
to increase due to the deterioration of water quality
during droughts or floods.
While acute malnutrition (wasting) rates have steadily
declined in LAC, and are generally below one per cent, the
capacity to monitor any sudden increase and to promptly
identify, refer and treat cases is still very limited in primary
and secondary health facilities. Spikes that can occur in
both emergency and non-emergency settings are often
under-reported, increasing the risk of mortality and
morbidity. In addition, exclusive breastfeeding rates are
reducing in most LAC countries and, despite LAC’s high
exposure to natural hazards, nutrition is too often seen by
national authorities as primarily a health service supply
issue or a problem that only needs food assistance to be
addressed.
Regional and sub-regional NiE coordination:
GRIN-LAC
Since 2013 UNICEF’s Regional Office for Latin America and
the Caribbean (LACRO), based in Panama, has been
supporting the development of a regional NiE group called
GRIN-LAC (Grupo de Resiliencia Integrada de Nutrición), to
strengthen NiE-related Disaster Risk Reduction (DRR), and
emergency preparedness and response. With financial

NUTRITION EXCHANGE 9
Governance and Coordination

support from USAID OFDA, coordination is assured by prioritisation of countries for support and monitoring
LACRO, in close collaboration with other development progress over time.
partners. GRIN-LAC also works closely with the Global
Nutrition Cluster (GNC) to improve the effectiveness of The Matrix goes beyond simple hazard and risk analysis to
humanitarian response programmes by ensuring greater examine specific nutrition-related vulnerabilities and
predictability, accountability and partnership. capacities at the country level. It is intended to:
1. Generate a model for defining minimum preparedness and
GRIN-LAC has explored some innovative approaches to response capacity for NiE at the national and regional level
directly engage national NiE focal points. While most in a standardised way, and monitor progress over time;
countries have people in charge of national nutrition 2. Develop a common understanding of preparedness and
programmes, many had not identified NiE as a priority area, response capacity (for resource mobilisation, planning
or group emergency-related activities under civil protection and promotion);
or other mechanisms. A lot of effort went into mapping 3. Improve the quality of regional and country-level
existing NiE focal points and, where these were missing, nutrition data; and
advocating for the need to appoint a specific person with 4. Identify gaps and facilitate convergence of efforts to
adequate qualifications. increase resilience.
Since the region covers 36 countries, GRIN-LAC relies on The GRIN-LAC matrix covers 32 countries in the LAC region
three sub-regional support groups (Central America, South and works at the national level by combining the values and
America and the Caribbean) to respond better to the specific indicators already included in the three dimensions of the
needs of the different contexts. The three groups, including INFORM model (Hazards Exposure, Vulnerability and Lack of
the national focal points, UN agencies, NGOs and other key Coping Capacity) with 12 nutrition-specific indicators. The
NiE stakeholders, have quarterly webinars, an online additional indicators constitute 40% of the model and are
document depository and a Facebook page for more rapid grouped under the vulnerability and capacity categories. The
news-sharing. additional nutrition indicators included in the GRIN-LAC matrix
In the past, regional NiE-related initiatives were very sporadic are intended to complement the one currently measured
and involved a limited number of participants, while now through the INFORM model, as well as add an additional level
representatives from 32 countries are regularly engaged and of analysis relevant to NiE. This is not an exhaustive list but a
have initiated concrete improvements. These regional and minimum set intended to capture some key aspects
sub-regional coordination and support mechanisms have influencing country preparedness and response capacity.
been very well received and have strengthened partnerships The GRIN-LAC Matrix allows us to achieve a consensual
across sectors, stakeholders and governments. They have starting point for the convergence of efforts and the
also facilitated the exchange of information and the monitoring of progress over time. The Matrix has been widely
systematisation of best practices and lessons learned and welcomed by regional and national counterparts and other
ensured greater effectiveness, predictability and partners and the model is also being adapted by other
accountability of NiE preparedness and response in LAC. sectors in LACRO (e.g. WASH and education).
The GRIN-LAC Matrix GRIN-LAC web page hosted by OCHA-REDHUM, main
A major challenge in the development of the GRIN-LAC document repository, including capacity building materials:
approach has been the lack of a standardised definition of www.redhum.org/sectores/12 GRIN-LAC’s Facebook page:
what NiE preparedness and response should be in LAC. To https://www.facebook.com/groups/GRIN.LAC/
address this, LACRO has proposed a tool (GRIN-LAC Matrix)
for the development of a standardised definition across 1
INFORM is a collaboration of the Inter-Agency Standing Committee Task
countries in LAC of minimum NiE preparedness and response Team for Preparedness and Resilience and the European Commission;
capacity to be used as a baseline, allowing for the more information can be found at: http://www.InfoRM-index.org

INFORM
Dimensions Lack of coping
Hazard & Exposure Vulnerability capacity
Socio- Vulnerable Institutional
Natural Human Groups Infrastructure
Economic
Categories
Earthquake

Development and deprivation (50%)

Inequality (25%)
Tsunami

Food

Tropical cyclone

Drought

Conflict intensity

Projected conflict intensity

Aid dependency (25%)

Uprooted people

DRR

Governance

Communication

Physical Infrastructure

Access to Health System

Other vulnerable groups

Components

10 NUTRITION EXCHANGE

Original article
Chatkal, Kyrgyzstan
Background
A disproportionately high number of the world’s hungriest
and most chronically malnourished people reside in
mountainous regions of the world (FAO, 2002). These
regions often have difficult climatic and topographic
conditions, scarce arable land resources and poor
infrastructure. Numerous impact studies (UNCTAD 2013,
CDE 2010) have shown the potential of programmes for
improving agro-ecological practices for poverty reduction
and nutrition impact, particularly in marginal and
mountainous ecosystems. However, these programmes
have not yet reached many remote communities living in
these areas.
In June 2015 IFOAM – Organics International1 launched a
Nutrition in Mountain Agro-ecosystems project (NMA) for
rural communities across five mountainous countries:
Nepal, Pakistan, Kyrgyzstan, Ethiopia and Peru. The NMA
project aims to link remote communities, diversify diets
through nutrition-sensitive agriculture, and facilitate
replication and scale-up of sustainable agricultural
practices to impact local, national and global levels. The
first phase of the project (2015-2018) is implemented by a
consortium and national partners2 under the lead of
IFOAM – Organics International. This article highlights the
Definition of micro-interventions
The likely MNA activities will focus on adapting agriculture,
marketing and consumption for better nutrition,
particularly of children and women, through increased
diversity of diets in a changing environment, including
social, economic and climate changes. The interventions are
identified through participatory methods and aim to have
a direct impact on the situation of small-scale farmers and
households in rural areas and generate insight and
knowledge on nutrition-sensitive interventions.
NUTRITION EXCHANGE
Nutrition sensitive programming
Shakhnoza Kurbanalieva
Nutrition in
Mountain
Agro-ecosystems
Shakhnoza Kurbanalieva has an MBA and
ten years’ experience in Kyrgyzstan and
Bangladesh and is currently coordinating the
Nutrition in Mountain agro-ecosystems project
at the International Organisation for Organic
Agricultural Movements (IFOAM).
approach and activities planned in the current phase.
Mountain in Agro-ecosystems Action Network (MAAN)
People living in mountainous areas often lack information
about the latest agricultural practices and have limited
access to and knowledge about diversified food. The
Mountain in Agro-ecosystems Action Network (MAAN),
initiated by the NMA project, is an internet-based social
and knowledge network of Rural Service Providers (RSPs)
around the world. RSPs are made up of government actors
(agriculture or health extension), civil society grassroots
workers and activists, community representatives,
progressive farmers and farmers’ organisations, business
agents (such as veterinarians, input salespersons and
buyers), teachers and many others interested in sharing
knowledge and learning about nutrition-sensitive
agriculture in mountainous areas. The use of the MAAN
virtual platform allows the RSPs to access ready-to-use
information, link with like-minded people, expand their
social and knowledge network, and to access training and
coaching through online discussions.
The NMA project offers a tailor-made Capacity
Development Programme for RSPs in each NMA country.
This consists of two face-to-face events at the beginning
and the end of the course with online interactions
throughout the MAAN platform. The course starts with a
call for RSPs to apply and present their ideas linked to the
needs of communities to improve nutrition status. The first
course took place in Pakistan following the Conference on
Nutrition Sensitive Agriculture in Mountain Areas, March
29-April 2 2016, in Islamabad, Pakistan.
1
Organics International (IFOAM) is an umbrella organisation of Organic
Agriculture worldwide. See www.ifoam.bio
2
Consortium partners are Helvetas and FiBL. National partners are Helvetas
Swiss Inter-cooperation in Nepal; Intercooperation in Pakistan; Bio Service
Public Foundation in Kyrgyzstan; Institute for Sustainable Development in
Ethiopia; and IFOAM Organics International in Peru.
11
 Nutrition sensitive programming
Advocacy and communications
The project focuses on the replication and scaling-up of
tested agriculture practices and food systems. Advocacy and
communication are a large part of the project. Advocacy
messages are developed from the results of micro-
interventions implemented by the RSPs during their training
programme.
The information and knowledge from the field is
continuously shared on the MAAN platform, which is
accessible to all users. The evidence-based information and
knowledge will be available after rolling out the Capacity
Building Programme. The national-level interventions are
concerned with knowledge-sharing that aims to improve the
national policies and engagements in nutrition-sensitive
agriculture, thereby improving the living conditions of the
rural poor. They also empower countries to take part in
global nutrition debates, based on the first-hand experience
of local, micro-intervention implementation for
duplication/scaling-up of successful approaches on nutrition-
sensitive agriculture.
The way forward
• At local level, the project relies on the internet-based
MAAN platform. Accessing the platform is a challenge in
some remote areas of target countries. To mitigate this
challenge, the project provides a mobile-phone version of
the platform and focuses more on physical meetings with
rural communities. The trainer RSPs are the key target
group to bring the knowledge and information from the
Original article
Promoting good dietary practices in Community
Early Learning Centres for children three to five
years of age in the Democratic Republic of Congo
Original article submitted in French
Tiphaine Bueke is a nutritionist and dietician working for the
UN Food and Agriculture Organization (FAO) and manages
the support to Community Early Learning Centres in DRC.
Background
The Community Early Learning Centre project
activities
The education system in Democratic Republic of Congo
(DRC) provides for the organisation of Community Early
Learning Centres (CELCs); facilities which are set up for the
education of children aged three to five years. Between
October 2012 and November 2013, UNICEF and FAO
joined forces to support the CELCs as they were facing
several operational challenges, such as payment of
teaching staff, the sale of agricultural products to support
the financial viability of the CELC teachers, and providing
children attending the centres with a nutritious and
balanced diet. A total of 62 CELCs were targeted for
support, 35 in Équateur and 27 in Bandundu provinces1.
12 NUTRITION EXCHANGE
communities into the MAAN platform and call the users
for debates and discussions.
• National-level activities rely on good collaboration and
relationships with national decision-makers like ministries
of health and agriculture who can influence national plans
and programmes on nutrition. Thus, based on the
evidence and messages collected from the micro-
interventions, it is important to align the project with
national committees and platforms, as well as initiate
synergies with like-minded organisations.
• Global advocacy is equally important to influence high-
level organisations in international fora. It is important to
obtain practical examples as actual evidence that can be
showcased to stakeholders in the global nutrition
discourse, as well as focus on players like the UN Food and
Agriculture Organization and the SUN Movement.
For more information, visit www.ifoam.bio/en/nutrition-
mountain-agro-ecosystems
References
CDE 2010. Impact Assessment - Organic Cotton in Jalalabad Oblast,
Kyrgyzstan, Centre for Development and Environment, January
2010.
FAO, 2002. UN Food and Agriculture Organization Press Release
16 June 2002. www.fao.org/english/newsroom/news/2002/
6763-en.html.
UNCTAD 2013. Report of the UN Secretary General on
Agricultural Technology for Development, UNCTAD Trade and
Environment Review 2013.
Financial autonomy for the committees supporting these
centres and the promotion of good dietary practice were
at the heart of the collaboration between the two UN
agencies, along with the Ministries of Education,
Agriculture, Fisheries and Livestock and Rural
Development. The overall aim was to reduce hunger and
malnutrition in the children attending.
FAO recommend promoting healthy diets and nutrition
through agriculture, integrating nutrition into agri-
business policies, programmes and projects, and sharing
the principles of a community’s right to food and
education. As the UN agency leading on education
matters, UNICEF supported the Ministry of Education to
implement and organise the CELCs.
1
Administrative division in 2014.
 Nutrition sensitive programming

proverbs related to daily activities; gender was analysed in

Charlotte Mubiala, CELC teacher

©Julien Zamuangana, March 2015, FAO, Kikwit Bureau

at La Fraternité, Masi-Manimba, Farmer Field Schools; and shared gender-related experiences
in her sesame seed garden were discussed through role play. This required know-how to
integrate a gender approach into all CELC activities. Trainees
received certificates only on completion of a five-day training
course and almost six months’ technical support in
accordance with the Farmer Field School facilitator training
programme.
Tools and vegetable seeds and vines of orange-flesh sweet
potatoes were distributed free to CELC teachers and parent
members of the CELC Committees. An estimated cumulative
total of 90 tonnes of vegetables and 5,379 tonnes of sweet
potatoes were produced, according to available project
The project reached 7,833 children aged three to five and monitoring data.
271 female early years teachers, 404 women and 689 men, Visits to the gardens were organised for children and they
making a total of 1,093 parents of pupils grouped within the took part in tastings of dishes prepared using produce from
CELC committees (Comités d’appui aux espaces the fields, which enabled them to benefit from hands-on
communautaires d’éveil). educational activities related to agriculture, food and diet.
The project was implemented on the basis of three essential Dietary habits were seen to improve in the project with the
components: increased consumption of fruits and vegetables reported
1. Developing the areas of agricultural production in the during focus group discussions with CELC members and
CELCs and promoting good dietary practice; monitoring surveys. The CELCs were therefore successful in
2. Harnessing community-level participation for the dedicating spaces for farming production and for the
intervention; and promotion of good dietary and nutritional practice. This led
3. Increasing the availability of foodstuffs rich in plant to more diversified consumption of vegetables as well as the
proteins, vitamins and minerals, as well as improving the opportunity to buy other foodstuffs using money from the
diet of children in the households concerned. sale of produce. Oil, sugar, salt and maize flour were all
The use of the faire-faire (‘making others do’) strategy, a bought with these funds. The CELCs also succeeded in
system whereby partners are invited to copy what they have ensuring that the teachers were motivated by being
seen, enabled FAO to establish a partnership with rewarded financially or in kind, albeit minimally, using the
government departments and local organisations. The produce grown in the fields.
results of this project are the fruit of a collaboration between Three years after the end of the project, the effects are still
the local Hirondelle Foundation , community radio stations visible. FAO and UNICEF are looking for further funds for
and parents of pupils in both provinces. scale-up.
The Farmer Field School methodology (Champ École Paysan)
was adopted to raise awareness and train members of the CELC La Fratenité (the fraternity)
CELC committee using media and establishing community growing sesame seed crop

©Julien Zamuangana, March 2015, FAO, Kikwit Bureau

listeners’ clubs. Community radio stations belonging to the
Hirondelle Communication network broadcast 151
programmes in French and Lingala or French and Kikongo,
depending on the intervention zone. In the province of
Bandundu, 190 men and 223 women came together in 36
community listeners’ clubs.
A total of eight topics were covered, including the right to
food, nutrition, market gardening, domestic animal
husbandry and the issue of gender and Farmer Field Schools;
these were addressed by experts selected by FAO.
The project included a capacity-building component on 2
The Hirondelle Foundation is a Swiss non-governmental organisation of
gender approaches by providing training for CELC staff. journalists and humanitarian professionals see www.hirondelle.org/
Women’s and men’s roles were discussed by analysing local index.php/ fr/qui-sommes-nous

In Masi-Manimba, Charlotte Mubiala, a teacher at La Fraternité ECE, shares her experience:

“Our CELC continues to operate. We currently have 47 pupils comprising 27 girls and 20 boys aged three to five years. Its continued
operation is made possible by the support we enjoyed from FAO and UNICEF: technical training, nutrition training and farming kits
containing tools and vegetable seeds. We have worked and our standard of living has improved compared to previously. We and our
pupils have been eating vegetables from our garden and continue to do so. We, the teachers, have been able to earn money by selling
vegetables from the garden. The habit of eating Chinese cabbage, headed cabbage, onions and leeks produced locally has now
become established in our homes. But we subsequently encountered a problem with sourcing good-quality seeds to carry on our
activities. We therefore organised supplies of seeds from Kinshasa using funds from the sales and added amaranth and tomato seeds,
both crops being particularly appreciated by the children in the area. As for me, I have specialised in producing amaranth seeds.”

NUTRITION EXCHANGE 13
 Nutrition sensitive programming
Original article
Keyhole gardens in Ethiopia: A study
of the barriers to scale-up
Yohannes Haile is a public health
professional working in Ethiopia
with Catholic Relief Services. He has
a Master’s degree in Public Health
from Mekele University in Ethiopia1.
Background
In 2005, the Government of Ethiopia established the
Productive Safety Net Programme (PSNP), which aimed to
address food insecurity in the most food insecure regions
of Ethiopia by targeting households that are chronically
and temporarily food insecure (PSNP, 2014). During the first
decade, the PSNP focused on important public works
resulting in improvements to rural infrastructure and
enhanced access to education and health services. It
included activities to mitigate the risk of economic and
climate-related shocks, such as soil and water conservation
activities, small-scale irrigation and integrated watershed
management. The latest PSNP (Phase IV) includes support
for the nutritional goals of the country and addresses long-
term income challenges. Catholic Relief Service (CRS) has
been implementing a food security project with livelihood
and maternal, child health and nutrition sub-components
in six districts of Dire Dawa since 2012 in support of the
PSNP. Keyhole gardens (KHGs) were used as a strategy to
help achieve improved maternal and child health and
nutrition and are the focus of this article.
A KHG is a two-metre wide, circular raised garden with a
keyhole-shaped indentation on one side.
KHGs were widely used in Southern Africa by a number of
actors2 involved in food security and nutrition
programming; the learning and success has now been
adopted in different parts of the world. The indentation
allows gardeners to add uncooked vegetable scraps, grey
water and manure to a composting basket that sits in the
centre of the bed. Keyhole gardens are relatively easy to
construct and emphasise the use of locally available
Yohannes Haile
Bedriya, beneficiary
of KHG in Meta
Hawibilsuma Kebele,
March 2014
14 NUTRITION EXCHANGE
resources. They mainly utilise locally available materials in
their construction, including stones, spades, thatching
grass for the central basket, small tree branches, manure,
wood ash and soil.
The KHGs aim to help improve household food security and,
in turn, the nutritional status of household members
through the production of a wide variety of vegetables
throughout the year. Pregnant and breastfeeding women
and mothers of children under five from poor households
were the primary target of the nutrition project. Health
Extension Workers (HEWs) and implementing partners
were trained on the step-by-step construction of KHGs and
then trained the target households. Training also included
the importance of eating nutritious food during
pregnancy and lactation and optimal feeding of infants
and young children. Cooking demonstrations at the
kebele (lower administrative unit) level were used as a
platform to discuss with mothers how to improve dietary
diversity and micronutrient consumption using the
vegetables they produce.
In total, 772 KHGs were constructed across the project area
from 2012 to 2015. The project monitoring reports indicate
an improvement in child-caring practices, food preparation
techniques and feeding practices. In addition, a significant
positive change reported was the priority of feeding
children under five a more diverse diet. According to the
mid-term project evaluation; 16% of children aged 6-23
months received four or more food types, a 7% increase
from the baseline (9%); 17% of children aged 6-23 months
received a minimum acceptable diet; and 74% of children
aged 6-23 months met the minimum meal frequency. This
exceeded the targets set for the third year (CRS 2015).
Despite these improvements, CRS staff and reports from
project implementing partners indicated potential
sustainability issues with the KHG technology. In
preparation for scale-up of the KHGs in the CRS supported
programmes, an assessment was conducted in July 2015 to
verify KHG numbers, functional status and adherence to
design specifications. The assessment revealed only 342
KHG were operational out of the 772 originally established
KHGs; i.e. less than 50%. A barrier analysis (BA) was therefore
undertaken to better understand what was happening.
Methodology for the barrier analysis
The BA used a rapid assessment tool to understand
perceptions and determinants associated with the
sustainable maintenance of KHGs. 90 women (purposively
sampled) engaged in the original KHG project were
interviewed. Of these, 45 were still cultivating (referred to
as ‘doers’) and 45 had stopped KHG activities (referred to
as ‘non-doers’).
1
Editorial support from Everlyn Matiri (Regional Technical Advisor -
Nutrition, CRS and John Steelman (Peace Corps Volunteer, CRS, Addis
Ababa, Ethiopia).
2
Consortium for Southern Africa Food Security Emergency (C-SAFE).
 Nutrition sensitive programming

Results assumption “If priority group leaders are trained and

The BA revealed six significant factors to sustaining the KHG: monitored using a structured BCC strategy on establishing
1. The non-doers were less likely to respond “Maintaining and maintaining functional KHG and on optimal nutrition
KHG is not difficult at all” and “KHG has no disadvantage at and are empowered to share their skills, experiences and
all” than doers did. Non-doers were also three times more testimonies with key beneficiaries, then sustainable
likely to respond “It is somewhat difficult to remember cultivation of KHGs will be promoted at grassroots level.”
and maintain KHG” compared with doers. This indicates
The BCC strategy will be used to design activities in PSNP
the non-doers had reasons for finding the KHG difficult to
Phase IV and CRS programmes. Activities will aim to build
maintain.
confidence in target individuals around the intervention and
2. Non-doers were more likely to respond “KHG can be used
reinforce their skills in maintaining functional KHGs year-
as a source of income by selling some of the produce,”
round. Monitoring will include the numbers of mothers
suggesting they valued the economic aspect of KHG,
trained, KHGs constructed and maintained, and tools for BCC
whereas doers were more likely to respond “KHGs build a
use. The new phase will focus on ‘lead mothers’, using a well-
healthy family and saves the cost of buying vegetables”
defined BCC strategy. One KHG demonstration site will be
respectively.
established for at least 30 households (previously the KHG
3. Non-doers were 2.4 times more likely to respond “It is
demonstration sessions were done at the kebele
somewhat likely that their child will become malnourished
administration centre level).
in the coming months,” while doers were 3.5 times more
likely to respond: “It is not likely at all” to the same The implementation area has repeatedly been affected by
question. drought and this might affect the routine implementation
plan of the project. CRS aims to mitigate this through use of
Participants who had working KHGs perceived them as a
drought-resistant crop varieties for the KHGs and by
means to build a healthy family and save on the cost of
introducing roof-harvest technologies to reserve water for
buying vegetables while also obtaining a source of income
use in the KHGs.
by selling the produce. KHGs were also perceived as a means of
preventing malnutrition. References
CRS, 2015. Keyhole Garden: Quality Improvement Verification
Conclusions and ways forward
Checklist Report July 2015. Catholic Relief Services of Ethiopia.
The results of the BA have been used to develop a refined
behaviour change communication (BCC) strategy to improve PSNP, 2014. Productive Safety Net Programme Phase IV: Programme
messages and activities to increase the impact of the KHG. A Implementation Manual. Ministry of Agriculture, Addis Ababa
behavioural change framework was designed on the December 2014.
Article summaries

Anganwadi Workers
being trained on
using the customised
mobile phone
application for BCSP Briefing on the Bihar
Child Support
Programme, India
Summary of Field Exchange 51 article by Oxford Policy
Management (OPM), India

I
n recent years there has been immense interest in Bihar,
India, in combating child malnutrition. Child malnutrition
rates in the state have declined over the past decade but
remain high in absolute terms. A survey conducted in 2014
found that 40.3% of children under five were underweight, 52%
were stunted and 19.2% were wasted. In Bihar, and across India,
Conditional Cash Transfers (CCTs) have been suggested as a
potential way to address this problem. There is limited evidence
so far of the impact of CCTs on nutrition outcomes.
The Bihar Child Support Programme (BCSP) is a pilot scheme in
261 centres that aims to contribute to the evidence base by
testing whether a CCT aimed at pregnant women and mothers
of young children can help improve child nutrition. Women are
OPM, India

registered at the end of the first trimester (three months) of

pregnancy and are eligible to receive 250 rupees (US $3.75) per

NUTRITION EXCHANGE 15
 Nutrition sensitive programming
month until their child is three years old if certain conditions
are met. There is also a set of bonuses when a child turns two
and three years old if a mother has not become pregnant
again and if a child is not underweight. In total, a mother can
receive up to 15,500 rupees (US$235), conditional on
meeting all conditions throughout the duration of her
programme enrolment.
The results so far show that, by the end of November 2015, a
total of 7,504 women were registered for the programme,
74% of whom met their conditions and received payment. In
addition:
WaterAid/ Ernest Randriarimalala
Pupils in Ambohimasina public primary
school, using the new sanitation block,
Analamanga region, Madagascar
The growing interest in
Nutrition and WASH:
Some new initiatives
and developments
I
Article summaries
nterest and commitment to nutrition-sensitive
interventions and multi-sector coordination has led
to an increased number of initiatives and
publications on nutrition and water, sanitation and
hygiene (WASH).
Inadequate WASH services and practices are a major
concern, with an estimated 663 million people worldwide
not accessing improved drinking water, and one third of
A recent WHO, UNICEF and USAID publication lists the
global-level commitments and policy basis for scaling
up joint nutrition and WASH interventions. It includes:
Nutrition and WASH as related human rights are
enshrined in Article 24.2(c) of the Convention on the
Rights of the Child urging states to ensure “adequate
nutritious foods and clean drinking water” to combat
disease and malnutrition (UN, 1989).
The 1992 and 2014 International Conferences on
Nutrition led country delegates to adopt the Rome
Declaration on Nutrition and the Framework for
Action, which recommends “actions on water,
sanitation and hygiene”.
The Global Nutrition Targets 2025 led the World Health
Assembly to call for combined actions in health, food
and other sectors, including WASH (WHO, 2012).
The Scaling-Up Nutrition (SUN) Movement partners are
working together to implement multi-sector action in
order to deliver nutrition-specific and nutrition-
sensitive interventions effectively and sustainably.
Source: Improving Nutrition Outcomes with better water,
sanitation and hygiene: practical solutions for policies and
programmes. (WHO, UNICEF, USAID 2015)
16 NUTRITION EXCHANGE
• There has been a steady increase in the number of village
health days across the programme area;
• The attendance of nurse midwives, other staff and stock
availability has improved considerably and;
• This has translated into increased attendance, higher rates
of pregnancy weight-gain monitoring, child-growth
monitoring and greater receipt of iron and folic acid
tablets by pregnant women.
The impact evaluation report will be finalised in 2016 and
summarised in a future edition of Field Exchange. This will
inform any decision to scale up and contribute to learning for
other similar schemes.
the world’s population lacking access to an improved
sanitation facility.
Notable recent publications on nutrition and WASH
include:
• Improving Nutrition Outcomes with better water,
sanitation and hygiene: practical solutions for policies
and programmes. (WHO, UNICEF, USAID 2015)
www.who.int/water_sanitation_health/publications/
washandnutrition/en/
• Multisectoral Approaches to Improving Nutrition: water,
sanitation and hygiene. Chase, C, Ngure, F. (2016). The
Water and Sanitation Program. www.susana.org/fr/
ressources/bibliotheque/details/2441
• The Impact of Poor Sanitation on Nutrition. Policy brief.
SHARE Research Consortium, London, UK; UNICEF
India, Delhi, India Chitty, A. (2015). www.susana.org/
en/resources/library/details/2387
• The Power of WASH – Why Sanitation Matters for
Nutrition. Spears, D, Haddad, L. (2015). International
Food Policy Research Institute (IFPRI).
www.ifpri.org/sites/default/files/gfpr/2015/feature_
3082.html
A specific Working Group on WASH and Nutrition has been
established under the Sustainable Sanitation Alliance
(SuSanA). The main aim is to examine the adverse
nutritional impacts of lack of safe WASH, particularly in
acute and chronic emergency situations. The group is
currently looking at the impact that faecally-related
infections can have on the nutritional status of children
and other vulnerable groups and has recently held online
discussions on this important area. Links:
www.forum.susana.org/forum/categories/92-nutrition-
and-wash and www.en-net.org/question/2437.aspx.
 Nutrition sensitive programming

Grace Heymsfield, Haiti, 2015

Article summaries
The nutrition-
sensitive potential
of agricultural
programmes in
the context of
Meals prepared for the school
school feeding:
feeding programme
Lessons from Haiti
Summary of Field Exchange 51 article by Nathan Mallonee,
Jason Streubel, Manassee Mersilus and Grace Heymsfield

H
aiti is the poorest country in the western
hemisphere, with 61.7% of the population
living below the international poverty line of
US $1.25 per day; 23.4% of Haitian children are
stunted and 10.6% are wasted. Haiti suffered from high
levels of undernutrition and food insecurity prior to the
devastating earthquake in 2010. Since this time, although
areas affected by the earthquake have seen improved
food security, a third of the population remains food-
insecure.
Since 2007, Convoy of Hope (COH) has implemented a
school feeding programme (SchFP), largely in primary
schools in Haiti. The project started supplying 6,000
children with a supplementary meal and was primarily
implemented through COH’s partner, Mission of Hope
(MOH). Community members prepared and served hot
meals to students each day of the school year. During 2013
and 2014, 425,000 meals were served weekly.
Each child received 11 grammes of protein and up to
100% of the recommended daily intake of vitamins and
minerals such as vitamin A, iron, zinc, and vitamin B12.
Servings were often supplemented by schools with locally
procured fruits and vegetables. Some schools also
received nutrition and hygiene training led by a Ministry of
Health community health nurse on topics such as hand-
Grace Heymsfield, Haiti, 2015
(266%) and pigeon pea (121%) yields. This translated to an
average increase in household income from US $2 per day
to US $7. Interviews and on-site tests showed improved
soil productivity and fertility, an increase in organic matter
and an increase in water-holding capacity. Importantly, the
project was also perceived locally to be a success.
Community leaders approached COH in early 2015 and
suggested that the agriculture project move on to other
communities. Key to the success of the project was the use
of church networks to implement the training, which
increased the trust of farmers.
Project challenges have included the difficulties in the
adoption of new farming techniques among farmers
before seeing the potential for increased profits; collecting
reliable anthropometric data which required adequately
training and motivating staff; and ensuring that the
agriculture extension projects are more nutrition-sensitive
by linking farming skills to school or community gardens
and looking for opportunities for increased hygiene-
promotion activities. Almost half of the agriculture
participants are women, which provides COH with the
ability to directly reach mothers with nutrition and
hygiene education in the classroom or in field agriculture
training sessions.

washing, cholera prevention and dental hygiene.

As the project scaled up, it led to an agricultural extension
programme designed to boost local production to enable
food supply to the SchFP and increase farmer income.
Activities included the provision of full-time access to a
trained Haitian agronomist, monthly educational
workshops and provision of seeds distributed to each
farmer for two or three different crops. Each individual
agreed to save 10% of their harvest as seed for subsequent
seasons and to donate 10% of the initial harvest back to
the SchFP.
Pre and post-season surveys revealed that from 2012 to
A nutritionist providing a hygiene lesson
2014, there was a ( 245% increase in black bean, sorghum as part of pilot WASH programme

NUTRITION EXCHANGE 17
 Nutrition specific programming
Original article
WFP/Ranak Martin
Assessment of the nutritional
condition of young children,
Bangladesh, May 2015
Background
Acute malnutrition (or wasting) among infants under six
months of age has been a neglected area, despite the fact
that younger infants are at greater risk of death than older
children. Save the Children is conducting research on the
management of acute malnutrition in infants (MAMI) in
Bangladesh with the aim of providing evidence for the
management of this condition. In partnership with the
ENN and the London School of Hygiene and Tropical
Medicine (LSHTM), a community-based tool for the
management of acute malnutrition in infants (C-MAMI) is
being developed to provide health workers with guidance
to identify, assess and manage acutely malnourished
infants in the community.
Bangladesh is very committed to providing nutrition
services through existing Ministry of Health district
services, although the concept of providing nutrition
services through community health workers (CHWs) is
new. For example, community-based management of
acute malnutrition (CMAM), despite being well known in
the sector, is not yet being implemented at scale. CHWs do
provide vaccination and family planning support door-to-
door in villages, although these staff are not trained to
identify acute malnutrition and are generally perceived as
being unqualified to provide any special nutritional care.
Methods, findings and conclusions
An exploratory study carried out in 2015 in the Barisal
district in Bangladesh involved semi-structured, in-depth
interviews with caregivers (mothers, fathers, grandparents
and other influential people) of infants under six months
of age and focus group discussions with CHWs and those
working at the Barisal Medical College Hospital. Interviews
captured the views, experiences and preferences in care of
infants with severe acute malnutrition (SAM).
18 NUTRITION EXCHANGE
Perceptions of severe
acute malnutrition
and its management
in infants under six
months of age:
An exploratory study
in Bangladesh
Yasir Arafat1 is a medical doctor and
public health practitioner, managing
community-based nutrition
programmes targeting acute
malnutrition. He is currently working
with Save the Children in Bangladesh
It was found that malnutrition in infants under six months
of age (known locally as opusti) is perceived as a common
problem in the community. The lack of a nutritious diet,
insufficient or no breastfeeding and repeated illness were
cited as the most frequent causes. Early marriage and
maternal malnutrition were also mentioned among other
common causes of malnutrition in infancy.
Symptoms associated with SAM include thinness, restless
sleep, crying, the inability to breastfeed and illnesses like
fever and cough. Mothers reported that they were most
likely to chose to go to CHWs, use home-based nutritious
foods, juices and keep the baby warm. Carers, including
grandparents and fathers, were more likely to report going
to traditional healers. Given the experience of door-to-
door visits from CHWs for other health-related activities,
home visits were cited as an appropriate way of
monitoring growth in infants.
While community-based treatment was identified as a low-
cost care option, not having a doctor in community clinics to
diagnose and ensure the appropriate management for
recovery was identified as a risk. In-patient treatment was
perceived to be a better care option because of the presence
of doctors and 24/7 care availability. Caregivers who
reported having experience of visiting these health services
were in favour of home-based management options as soon
as their infant had overcome the most critical period, so as
not to have to spend so much time away from home.
Communities felt that supporting the mother while she
cared for a malnourished infant was just as important as
1
Contributions to this article came from G. Mothabbir at Save the Children
in Bangladesh, N. Connell at Save the Children USA, M. Kerac at the
London School of Hygiene and Tropical Medicine and MM. Islam at the
International Centre for Diarrhoeal Disease Research.
 Nutrition specific programming

caring for the infant. This notion of wellbeing was extended to

support for decision-making on whether to take an infant
presenting symptoms identified with SAM to the nearest
government facility or to treat the infant at home.
Training of caregivers and health workers was cited as a way
forward where there is no availability of qualified medical staff at
community level. Mothers also reported being confident in
taking care of their infants if they were taught to provide better
home-based care. They expressed a preference for in-patient
care in hospitals only when there was no other option due to the
seriousness of the health status of the infant.
The study indicates that there is a preference for community-
based, mother-infant care options due to the issues of access to
in-patient care and because of trusted community support
mechanisms. Early diagnosis and treatment of SAM at home
through reinforcement of a community-based approached

Yasir Arafat
based on early detection may be a way forward. Yasir training data
collectors at field
http://www.ennonline.net/c-mami
Original article

The challenges faced in providing

sustainable management of acute
malnutrition services in Ituri Province,
Democratic Republic of the Congo
Original article submitted in French
Cosma Bakemwanga Sapeke is the coordinator of the Ituri National
Nutrition Programme (Pronanut by its French acronym) in Bunia, Democratic
Republic of Congo. He has worked at the Ministry of Health since 2002

T
he Democratic Republic of Congo (DRC) has a
population of almost 75 million, of whom two
thirds live below the poverty line. The DRC is
characterised by ongoing conflict, poor
infrastructure and highly challenging logistics, all of
which have had a severe impact on the health
infrastructure and government-funded services. Conflict
in the eastern provinces causes continued displacement.
According to DRC’s Demographic and Health Survey
2013-14, among children under five, 43% are stunted and
8% are acutely malnourished (wasted), with ten territories
having rates of acute malnutrition above the emergency
threshold of 15%.
Making the benefits of a post-conflict or emergency
nutritional intervention sustainable is a necessary process,
but it is not always easy to implement and can sometimes
lead to frustration in the performance of the programmes.
Ituri Province in the east is notorious for conflict and
violence and the population shifts that have taken place
over the last ten years. As in most of the country, the
population has very limited access to basic social services
such as health, education, drinking water and electricity.
The area has witnessed various changes of strategy for the
management of acute malnutrition, alternating between a
focus on treatment with excellent results but with low
programme coverage and the exclusion of the community
from the programme, to a focus on more integrated
approaches with the health sector and the prospect of
greater sustainability, but which is more problematic in
terms of programme quality.
Local solutions for local problems
The Rimba health zone in Ituri Province was supported by
an international NGO, but in 2008 the partner withdrew its
support and the responsibility was transferred to the
National Nutrition Programme (Pronanut). Integration of
the management of acute malnutrition (iMAM) in the
health system is now effective and functional, but the
regular supply of treatment products remains a major
challenge. The health zones are dependent on outside
supplies and they have no control over quantities or
delivery times. This often leads to stock shortages. In the
face of frequent shortages of therapeutic milk, some of the
therapeutic nutrition units follow the WHO recipe with
dried skimmed milk to make therapeutic milk. Maximum
care is given, but the protocol is not strictly adhered to,
resulting in excessively high death rates in the Therapeutic
Feeding Centres (Unités de Nutrition Thérapeutiques – UNT),
as well as low recovery rates and a high turnover. These

NUTRITION EXCHANGE 19
 Nutrition specific programming
WFP/Ranak Martin
Agricultural project in Democratic Republic Of Congo
stock-outs impact on the quality of care as well as on the
motivation of the staff.
The health authorities in Ituri have decided to also focus on
preventative activities and to do so by integrating nutrition
into other sectors. This includes promoting the early
initiation of and exclusive breastfeeding, adequate
complimentary feeding, strategies to address vitamin A, iron
and iodine deficiency, deworming and the consumption of a
varied diet.
In order to foster preventative approaches to addressing
malnutrition, it has been necessary to involve other partners
to cover all the health areas.
The leadership of local authorities, in the framework of the
Local Nutrition Committee (Comité Locale de Nutrition – CLN),
has also been instrumental to ensure this coverage. For
example, designated land is used for farming demonstrations
by extension workers, promoting the planting of diversified
crops rich in nutrients (beans, peanuts, sweet potato, tomato
and aubergines) for local consumption by households with
malnourished children and they have set up women’s
Original article
Niger Nutrition Alliance
Maïté Bagard has been the Niger Nutrition
Alliance Coordinator since January 2015.
Background
In Niger, acute malnutrition (wasting) in children is still a
major public health issue. In 2014, a national nutritional
survey reported a prevalence of acute malnutrition of 18%,
of which 2.7% was severe acute malnutrition (SAM) in six
out of the eight geographical regions of Niger. Many
agencies have been supporting activities to address
undernutrition in Niger. This article describes the work of
the Niger Nutrition Alliance.
The Alliance, formed in 2013 with funding from European
Commission DG ECHO, is a network of non-governmental
organisations1 acting to prevent and manage SAM in Niger.
It provides a platform for communication, partnership,
advocacy and sharing of best practice, and members are
20 NUTRITION EXCHANGE
farming groups and provided education on healthy eating.
In the Rimba health zone, an appeal to the FAO has enabled
seeds and tools for tilling to be distributed in 18 health areas.
Members of the CLN have thus been able to promote locally
produced food thanks to the support of women’s agricultural
associations in the region.
Community participation and capacity-strengthening have
enabled the communities to participate in identifying
problems and tracking cases of malnutrition. Nutritional
screening at community level still exists, even if it is not as
intensive as when NGOs supported these activities through a
financial incentive. The involvement of the people concerned
is vital to ensure the sustainability of these activities.
Conclusions
It is essential that good-practice examples, such as that of
Rimba health zone’s new approach focusing on preventative
measures, be taken up by others if malnutrition is to be
prevented. It needs to be recognised as being part of a multi-
sector approach and the responsibility of all concerned.
The experience of Ituri has shown that the best method of
combatting malnutrition is integration of nutrition activities
into the existing health system – ensuring sufficient financial
resources and systems to provide an adequate supply chain
for nutrition products where treatment is needed – and the
development of mechanisms to prevent new cases of
malnutrition through raising awareness and increased
production and consumption of locally produced,
micronutrient-rich foodstuffs.
Previous high levels of international actor investment to
address acute malnutrition cannot be maintained once the
nutrition partner and the funding goes; however it is hoped
that with time, the previous implementation experience can
be adapted in line with will local capacity and resources.
supported to adopt a common discourse and harmonise
their approaches.
From 2013 to 2015, the Alliance has strengthened
engagement among partners through meetings,
document exchange, presentations and advocacy events.
Alliance partners have increased cooperation with other
actors involved in nutrition, particularly the Government
initiative I3N, Nigeriens feed Nigeriens2, the National
1 French Red Cross, Concern Worldwide, Save the Children, Action Against
Hunger, Cooperazione Internationale, Alima/Befen, Internationale Rescue
Committee, Doctors of the World France
2 Nigeriens Feed Nigeriens (Les Nigériens Nourissent les Nigériens) is a
Government initiative that was launched in 2012. It is chaired by the
President of Niger.

Technical Group on Nutrition, the National Directorate of
Nutrition, local NGOs and the SUN Movement. One key
success of the work of the Alliance was the standardisation of
Memorandums of Understanding between Regional
Directorates of Public Health and nutrition partners, which
support a legal framework of roles and responsibilities of all
actors. Based on the increased collaboration and initial
achievements, ECHO renewed funding for the Alliance for
2015 and 2016.
Progress made in 2015
In 2015, Alliance members continued to work alongside local
authorities and decentralised technical services, such as the
regional health authority and district management teams, for
the management of SAM in 20 out of 42 health districts in
Niger. This was intended to benefit nearly 200,000
malnourished children under five years of age. In addition,
Alliance members capitalise experiences and harmonise
processes in implementing nutrition activities for SAM and
enhance and increase advocacy capacity among national
policy-makers so that the cost of treatment and prevention
of malnutrition is integrated into existing policies and
financed to support longer-term nutrition programming.
The harmonisation of implementation tools, monitoring and
evaluation, sharing of information, analysis and research and
development of common advocacy messages allow Alliance
members to speak with a single voice using data from each
other's experiences. A new initiative in 2015 was the
compiling of quarterly reports from members on their supply
chain of nutritional commodities and using those reports to
advocate for better coordination with UNICEF.
The Alliance has been involved in revising a practical tool
(admission, caring practices, roles and responsibilities) to
integrate improved supervision of services to optimise the
management of acute malnutrition. The tool is about to be
validated and disseminated in Niger in 2016.
Additional key efforts for 2016 include the following:
• Local advocacy
An important component of the programme in
transitioning from emergency to the development
phase of the health system is advocacy. Efforts revolve
ALLIANCE ONG NUTRITION & ECHO/HIP 2015
CRF
Save the Children
Alima/Befen
IRC
Concern
MDM
Coopi
ACF
Carte réalisée par ACF-E décembre 2014
NUTRITION EXCHANGE
Nutrition specific programming
around active participation in local and national planning
meetings to advocate for commitments made in 2014 by
the municipalities, the communities and the authorities,
including support for required health and nutrition
supplies and support to the Ministry of Public Health to
recruit 500 additional nurses in rural Nutritional Recovery
Centres where Alliance partners operate.
• National Advocacy
The Alliance played an active role by making
presentations on progress at major events, including
the review of the roadmap for Integrated Management
of Acute Malnutrition. This needs to continue in 2016.
Alliance members are actively involved in the
development of the new National Health Development
Plan with an aim to ensure the inclusion and appropriation
of funds for nutrition (including prevention and
management of acute malnutrition) in a framework to
strengthen the health system.
• Common diagnostic tool
One of the Alliance’s current major objectives is to develop
and implement a diagnostic tool that outlines the
targeting and type of assistance to be provided to support
ownership of the management of malnutrition by the
Government and local communities. The tool is based on
the WHO minimum standard of quality for health centres
and validated by the National Department of Nutrition.
The aim is for Integrative Health Centres to use the tool to
tailor a plan to improve the quality of services. The tool
was used in 20 health districts to establish a baseline and
set benchmarks for evaluating the level of integration of
the services.
• Continued networking
While there is a shift from emergency to development
programming in Niger, the Government will remain donor-
dependent for treatment and prevention of acute
malnutrition. New partners have joined the Alliance in
2016 and it is planned to promote exchanges with the SUN
Movement, UN agencies and all the nutrition partners.
Furthermore, relations with the Food Security Alliance will
be consolidated. The Alliance will continue to strengthen
the Nigerien health system and support actors in
capitalising on learning during this transition process.
WFP/Rein Skullerud
A maternal and child healthcare
center in Niamey, Niger
21
 Nutrition specific programming
Original article
Mobile clinics as a strategy to identify and
treat children with acute malnutrition in
difficult-to-reach areas in Chad:
A case study of the Wadi Fira Region
Original article submitted in French
Dahab Manoufi is an economist and manages the NGO Bureau d’Appui Santé et
Environnement (Health and Environment Support Bureau), Chad.
Dr Hervé Oufalba Mounone is a doctor and coordinator at the NGO Bureau d’Appui
Santé et Environnement (Health and Environment Support Bureau), Chad.
Background
Like most countries in the Sahelian belt in Africa, Chad
experiences high levels of acute malnutrition (often
referred to as wasting) which regularly exceed emergency
thresholds of 15%. Acute malnutrition rates in Chad have
remained consistently high over the last ten years and
levels of stunting have increased from 28% to 39%. Almost
one in five babies is born with low birth weight, and only
three per cent of women practise exclusive breastfeeding.
Rates of acute malnutrition are even worse in the
populations living in difficult-to-access areas, such as the
Wadi Fira Region, situated on the far eastern side of Chad1.
The causes of malnutrition in Wadi Fira are multiple, but
key are the barriers to accessing health services due low
population density, the long distances that separate
villages from healthcare facilities, and insufficient staff in
quantity and quality. Added to this is the restricted
22 NUTRITION EXCHANGE
mobility of household members caused by high poverty
levels, which means households have to dedicate their
time to subsistence livelihoods, and where women lack
decision-making power.
This article describes how mobile health clinics with
nutrition outreach activities were supported in one of the
most difficult-to-access areas in Chad.
Nutrition surveys carried out between 2010 and 2015
have revealed high levels of acute malnutrition in the
eastern Chad provinces (at times rates have been close to
25%), and a high caseload of children under five years of
age in need of immediate treatment of the severest form
of acute malnutrition. In response to this, BASE (the Health
and Environment Support Bureau), a non-government
organisation, initiated a community nutrition and health
project in 2011. The strategy was to implement mobile
clinics for hard-to-reach populations who do not benefit
from fixed-point health services. With financial support
from UNICEF and the WFP the project, initially planned for
a year, has twice been renewed and covered the three
districts of the Region until December 2014.
Mobile clinic activities
Priority was given to villages located over 5km from a
health centre that were difficult to access due to limited
means or terrain. Figure 2 shows the implementation of
the activities in the three districts.
Mobile team nutrition activities were overseen at the
Regional Health Delegation headquarters by a team of
three health staff: a medical chief officer (médecin chef de
projet); a nutritionist in charge of all training activities and
supervision of the application of the national nutritional
protocol of management of acute malnutrition; and an
administrative/financial assistant.
At the Health District level, six mobile teams were formed,
made up of two nurses, a midwife and two measurement
officers. These teams were organised to support the
health staff responsible for the health centres in 47 sites
covering all three health districts. Each Health District had
a nurse supervisor and a community mobiliser who took
1 INSEED. Nutritional study 2010.
 Nutrition specific programming

MAM admissions between 2012 and 2014 in the BASE-supported nutrition

Figure 1 project in the Wadi Fira Region

2000

1800

1600
MAM admissions

1400

1200

1000

800

600

400

200

0
Jan 2011

Mar

May

Jul

Sept

Nov

Jan 2012

Mar

May

Jul

Sept

Nov

Jan 2013

Mar

May

Jul

Sept

Nov

Jan 2014

Mar

May

Jul

Sept

Nov
2011 2012 2013 1014 Mobile clinic in Chad

on the logistics, monitoring and data collection activities of crisis due to drought in the Sahel. The number of
relating to the work of the mobile teams as per the admissions continues to be relatively constant after June
implementation of the joint quarterly plans set out by the 2012, suggesting that outreach activities using the mobile
District Level Management team (Equipe Cadre de District). clinics may have contributed to increased attendance at a
time when prevalence levels of acute malnutrition would be
The activities carried out by the mobile team included
expected to rise during the lean season (May to October), but
measurement of mid-upper arm circumference (MUAC) for
admissions have been fairly regular3.
screening for cases of acute malnutrition and arranging for
severe and complicated cases to be referred to the Lessons learnt
therapeutic nutritional units (unité de nutrition thérapeutique) The involvement of communities, the provision of transport
in the district hospitals (in Biltine and Iriba). Transportation for referred children (and their carers) and food assistance are
was provided from the mobile clinics for patients referred to key factors that helped mothers to accept the referral of their
the hospital and their return home once they had recovered. children to the hospitals. On the other hand, the cost of
Community involvement was ensured through four to six implementation, the lack of integration with other services
community mobilisers per village who supported screening and an unreliable supply chain of supplementary, ready-to-
activities, looking for defaulters and making home visits for use foods limited the scaling-up of such an approach by the
children who were not gaining weight. They were also health authorities.
involved in supporting the health mobilisers and nurses in
their sensitisation activities around basic household-level Even though this project allowed children suffering from
practices. different degrees of acute malnutrition to be referred and
treated, it was not focused on preventative actions that could
In January 2011, the number of children being admitted for have further reduced the prevalence of acute malnutrition in
the treatment of moderate acute malnutrition (MAM) based this population. Acute malnutrition in Chad is still too often
on a MUAC of 115-125mm in Wadi Fira was 200. Treatment for perceived as a short-term problem and not a structural one.
MAM includes the use of a supplementary, ready-to-eat food
supplied by WFP that promotes weight gain. When the BASE
nutrition project activities began in October 2011 this Figure 2
number started increasing, as shown in Figure 1 below, with
over 10,000 treated during 2014. This increased the number
Regional Health
of children being treated for MAM considerably during the Delegation Project
project in a remote area of Chad where the national coverage Coordination Team:
Medical chief, Nutritionist;
rates for MAM are estimated at less than 15%. Seasonal Administrator
variations in rates of acute malnutrition were reflected in the
admissions patterns, as was the drop in the number of
Health Mobile Teams:
children admitted in April and May 2013, which corresponds Supervisor nurse,
Districts
to a project funding gap when mobile teams were not Community
Mobiliser
operating. (Note: these figures are representative of the
BASE-supported project areas only.) Health
Centre:
The BASE project admissions data presented above reflects a Mobile clinic: Five community
1 Team Leader, volunteers
very low number of admissions at the start of the project in 1 Nutrition assistant,
1 Midwife, 2 Measurers,
2011 and then a steady increase over 2012, which was a year 1 Driver, 4 Community
mobilisers
2
BASE 2011, 2012, 2013 and 2014 activity reports.
3
UNICEF. Report on the Sahel nutritional study. 2014.

NUTRITION EXCHANGE 23
 Nutrition specific programming
Original article
Volunteers in a session
Halima Hillow is a nutritionist working in Somalia with World Concern. She has a
degree in Food and Nutrition from the Ahfad University of Women in Sudan and is
currently writing her Masters thesis in Public Health at Kenyatta University, Kenya.
C
eel Afweyn District is in the northern Sanaag
region of Somaliland with a population of over
117,000. The topography is a combination of
mountainous and flat areas and the population
is traditionally pastoral, although since the severe drought
of 2011 some have moved into other livelihoods, such as
commerce and starting small village shops. Access to
healthcare services is limited, with only one well-
functioning maternal and child health (MCH) centre and
two smaller health posts managed by auxiliary nurses with
the capacity to treat only minor, common illnesses. The
roads are poor and largely inaccessible during the rainy
season, further limiting access to markets and the MCH
centre.
World Concern1 is implementing a two-year nutrition
project in nine villages (total population 12,600) in the
district. The project aims to prevent malnutrition in
children under five years of age and in pregnant and
lactating women. Wasting levels are high at around 10% in
the project area. The project objectives are to:
(i) Improve infant and young child feeding (IYCF)
practices;
(ii) Improve maternal nutrition and health care; and
(iii) Improve hygiene and sanitation (personal, food and
environmental) and utilisation of safe water.
Baseline, mid-term and end-line evaluations have been
designed into the project, which includes measuring
nutritional status in the project area as well as underlying
causal factors.
The project is focused on promoting behaviour change
through the Care Group model2, which aims to create
individual and community behaviour change in health,
nutrition and hygiene. This model was chosen based on its
success in other countries and its focus on simple
messaging to mothers.
24 NUTRITION EXCHANGE
Halima Hillow
Improving
nutrition
behaviours
through a
Care Group
Model project
in Somalia
Eighteen Care Groups were established across the nine
villages. The groups were led by nine Health Promoters
(HPs) and supported by 248 Care Group Volunteers (CGVs),
selected by community members and whose primary
function is to visit households at least once a month, but
often more frequently, and deliver key nutrition and
health messages to promote behaviour change around:
a) IYCF (timely breastfeeding, exclusive breastfeeding,
continued breastfeeding up to two years and
complementary feeding);
b) Nutrition and maternal care in pregnancy (importance
of proper nutrition with the available resources and
the importance of attending MCH clinics);
c) Water, sanitation and hygiene (essential hygiene
actions such as water transportation, purification and
storage, hand-washing and prevention and
management of diarrhoea.
The approach is based on community participation; the
HPs receive a monthly incentive of $80, while the CGVs are
given lunch allowances during the trainings.
Results
World Concern conducted intense trainings for the HPs
and CGVs and 221 CGVs graduated in September 2015
after covering topics in essential health, nutrition and
hygiene. The trainings were conducted using adult
training methodologies and in the local language to
enhance acquisition of knowledge by the volunteers, as
most of them were previously unschooled. Cumulatively,
the CGVs made 11,666 household visits to deliver key
messages to households on health, nutrition and hygiene
in the first year of implementation.
1 World Concern is a global relief and development agency.
2 The Care Group Model originated in Zimbabwe and has been used in 22
countries worldwide.

During the project inception period, it was identified that
many mothers did not breastfeed their newborns
immediately after delivery because they were tired and did
not feel they could breastfeed. Health messages were
designed accordingly and health promoters have worked
closely with traditional birth attendants to promote
breastfeeding immediately after delivery.
A cross-sectional baseline survey carried out in December
2014 and a mid-project evaluation in October 2015
(involving samples of 330 and 349 households respectively)
were conducted in nine villages. Mothers with children
under five years of age were interviewed; this showed
significant reported improvements in all but one of the
promoted behaviours (use of mosquito nets) from baseline.
A comparison of the survey results also shows a significant
decrease in reported cases of child diarrhoea, increases in
reported hand-washing, exclusive breastfeeding and
breastfeeding in the first hour after birth (see Figure 1
below).
Figure 1 shows the very positive reported changes in rates
from the baseline survey and mid-line surveys for timely
breastfeeding, exclusive breastfeeding, hand-washing
practices at critical times and incidences of diarrhoea in the
two-week period. As these are reported rates of behaviors,
they cannot be assumed to reflect actual changes in practice
as it may be that mothers are reporting what they feel the
interviewer wants to hear. Nonetheless, the findings after just
ten months of intensive behaviour change communication
activity are very encouraging.
The CGVs focussed on essential hygiene actions such as
water transportation, purification and storage, hand-washing
and diarrhoea prevention and management. Discussion with
Care Groups showed that they had understood the need to
manage water sources well. Currently they are working with
the committees who manage the water points to ensure they
are always clean and that the animal drinking points are
separated from the human-use points. Some members of the
Care Groups have made tippy taps (a simple device for hand-
washing with running water) in their house and act as a
model to others. World Concern continues to promote
increased uptake of these taps.
Challenges
The project has faced several challenges, including:
1. Poor access to health services. Currently, the Somali Joint
Health and Nutrition Programme (JHNP) is being
implemented in some parts of the country, but it has not
reached the very remote areas. JHNP is a comprehensive,
Reported nutrition behaviours at baseline
Figure 1 and mid-term survey points
A village health commitee member
in a training session
Diarrhoea in the two 8.6%
weeks prior to survey 26.7%
Hand-washing knowledge 56.8%
(4 critical times) 10.4%
Exclusive breastfeeding 78.7%
(0-5 months) 9.2%
Breastfeeding within the 78.7%
first hour 17.5%
2015 2014
Halima Hillow
NUTRITION EXCHANGE
Nutrition specific programming
multi-donor, development programme aimed at helping
Somalia meet its commitments on maternal and child
health. The project continues to advocate to the Ministry of
Health for the need to expedite the selection of partners
and funding for the JHNP in this under-served area.
2. Lack of access to nutritious foods. While mothers receive
messages and training on the importance of providing a
balanced diet to their children, the main challenge is the
limited availability and access to nutritious foods. World
Concern has plans to support groups to develop kitchen
gardens to supplement their diet for the remaining year
of the project.
3. Limited availability of volunteers during the dry months.
Some of the mothers in the Care Groups are pastoralists
and occasionally move with their animals to look for
pasture and water during the dry months, coming back
after a month or two. Health promoters try to ensure
they are provided with the information they have missed
while away, although the gap in contact and follow-up
remains challenging.
4. Discontent amongst males due to lack of training. Since
Care Groups mainly focus on behaviour change targeting
women, the males in the villages have reported that they
are upset that they do not receive any training. World
Concern is therefore involving men by including them in
the village health committees, in which two thirds of the
members are male and a third female, and holding
monthly meetings for men to discuss messages that are
being promoted in the Care Group.
5. Low literacy levels. The majority of the volunteers are
illiterate and unable to read the key messages provided
by World Concern. Health promoters are literate and
work to overcome this by going through all the messages
clearly to ensure that all volunteers understand.
Conclusion
The project is in the final year of implementation and will be
finished in October 2016. World Concern is engaging Care
Groups in discussions on mechanisms that could be
employed to sustain them after the project ends and is
optimistic that the JHNP will soon start in the area, adopting
the Care Group model. The extension of the JHNP and the
continuation of community support for health and nutrition
will hopefully provide stronger and more sustainable links to
the healthcare system. Additionally, World Concern has
shared evidence from this project and advocated to Somali
Nutrition Cluster partners the integration of the Care Group
Model into their health and nutrition programmes in order to
improve health and nutrition for women and children based
on the positive experiences of this project at community level.
25
Scaling Up Nutrition
Bangladesh, Chittagong
Hill Tracts, Bangladesh
WFP/Shehzad Noorani
T
he second SUN Movement Strategy and Roadmap
(2016-2020) builds on the collective commitment
generated by the 56 countries that are driving the
SUN Movement as they seek to end malnutrition in
all its forms. The political will has never been stronger;
however, moving to impact at scale and ensuring sustainable
results for all is now at the heart of the SUN Movement’s
strengthened approach.
The new Strategy and Roadmap calls for greater emphasis on
implementation and accountability and has the following
four objectives;
1. Expand and sustain the enabling political
environment;
2. Prioritise and institutionalise effective actions that
contribute to good nutrition;
3. Implement effective actions aligned with national
common results frameworks;
4. Effectively use, and significantly increase, financial
resources for nutrition.
In support of these objectives, the SUN Roadmap focuses on
strengthening country capabilities through:
Improving policy and budget cycle management in order to:
• Have nutrition plans in place, endorsed at the executive
and ministerial levels, with defined national nutrition
targets and costed actions that guide aligned
implementation and resource-allocation;
• Regularly and transparently track budget allocations
against the plans and demonstrate better use of
finance data through improved advocacy, planning and
impact;
• Increase resources for nutrition from both domestic
and external sources;
• Analyse and use good quality data for decision-making,
accountability and advocacy and through all of the above;
• Implement agreed actions at scale and demonstrate
the impact of these actions.
Undertaking social mobilisation, advocacy and
communication in order to:
• Keep building and sustaining political, institutional and
financial commitment at all levels;
• Maintain advocacy and communication which support
the realisation of national priorities;
• Share country lessons and progress, stimulating
country-to-country knowledge-sharing.
Build the capacity of individuals and institutions in order to:
• Ensure high-performing, multi-stakeholder platforms,
26 NUTRITION EXCHANGE
UPDATE:
The Scaling Up
Nutrition (SUN)
Movement Strategy
and Roadmap
(2016-2020)1
with effective coordination at subnational levels;
• Enable all key stakeholders to make measurable
contributions to scaling up nutrition;
• Have aligned political commitment, policy and legislation,
in support of nutrition;
• Prevent and manage conflicts of interest as they emerge,
promoting effective collaboration.
Strengthen the equity drivers of nutrition,
including roles of women and girls.
Equity lies at the heart of the nutrition challenge and the
Roadmap will support a shift from rhetoric to action. It will
help support SUN Countries to prioritise:
• equitable improvement in the nutrition status of all
people, ensuring that no one is left behind;
• policies that reduce nutritional inequities, especially
among women and girls and eliminate discriminatory
laws and practices.
At the core of these services are the SUN Movement’s
Principles of Engagement, which guide the myriad of actors,
all working to scale up nutrition.
Process to date
At their meeting in September 2015, the SUN Movement
Lead Group tasked the new SUN Movement Executive
Committee to oversee the development of the Roadmap to
ground the high-level ambitions of the Strategy in practical
actions that will have greater impact at country level.
Through a consultative process (kick-started at the SUN
Movement Global Gathering in 2015), working groups were
established to set ambitions for the coming five years.
Facilitated by the SUN Movement Secretariat, with
stakeholders drawn from the membership of SUN Countries,
SUN Networks (UN, Civil Society, Donor and Business) along
with academic and technical partners, the Roadmap was
reviewed.
The final Strategy and Roadmap will be endorsed and
launched by the incoming SUN Movement Coordinator, Ms.
Gerda Verburg and the Lead Group, in July 2016.
It will continue to be a country-led, multi-stakeholder and
multi-sector collective force for nutrition.
For more information on the SUN Movement, please visit
www.scalingupnutrition.org
1
This update was kindly written by the SUN Movement Secretariat.
 Scaling Up Nutrition

A andean woman climbs down a

steep mountain to reach the piece
of land where her animals graze

ENN’s Knowledge
Management Project
in support of the
SUN Movement
Tui Swinnen is the Global Knowledge
Management Coordinator at ENN

WFP/Edward Alba

I
n early 2015, ENN began work on a five-year project to strong networks in their respective regions. The ENN KM
support Knowledge Management (KM) for the Scaling team will develop a thorough understanding of knowledge
Up Nutrition (SUN) Movement under a DFID-funded needs at country and regional levels within the SUN
Technical Assistance for Nutrition (TAN) programme. Movement and will foster intra- and inter-regional learning
The programme is designed to support countries to seize the and exchanges.
opportunity presented by the favourable political
In addition to using existing ENN networks, publications and
environment that has been created for nutrition globally and
platforms, including en-net, Field Exchange and Nutrition
to maximise the benefits of membership of the SUN
Exchange, ENN will develop new tools and approaches for
Movement. The Micronutrient Initiative (MI) is also funded
KM in order to meet the needs of actors involved in the SUN
under the TAN, with a focus on delivering technical
Movement at the national and sub-national level. Regional
assistance support to countries within the SUN Movement.
learning events will be organised to focus on specific
With the SUN Movement now in its second phase (2016-
learning and ENN will develop more digital content and
2020), TAN partners will provide ongoing support to actors
interactive online spaces to improve networking among
involved in scaling up nutrition with a focus on
country level actors and the capture and exchange of
implementation and experience at country level.
learning and know-how.
ENN’s KM work will focus on supporting actors within SUN
ENN will continue to expand its audience and network,
countries to identify knowledge gaps, strengthen evidence
engaging actors involved in scaling up nutrition from all
on effective nutrition scale-up, and share know-how among
sectors and networks, which will bring new voices,
actors involved in multi-sector programming and policy-
perspectives and lessons on scaling up nutrition to help
making. ENN will pay particular attention to countries within
strengthen the SUN Movement and the scale-up of nutrition.
the SUN Movement that are fragile and conflict-affected,
ENN will also ensure key KM-related materials are translated
recognising the unique challenges faced by actors involved
into the languages needed in order to reach out to new
in scaling up nutrition in these contexts. Furthermore, ENN
audiences at national and sub-national levels.
will harness the opportunity to improve knowledge-sharing
and coordination between actors in both humanitarian and For more information, please contact Tui@ennonline.net and
development nutrition sectors that often exist side by side in follow us on Twitter @TuiSwinnen and @ENNOnline.
fragile and conflict-affected contexts.

Progress to date
ENN has undertaken extensive consultation with a wide
range of stakeholders and regional scoping visits to Somalia,
Kenya, Ethiopia, Zambia, Senegal, Myanmar, India,
Bangladesh and Laos to understand the status of the SUN
Movement in these countries and their KM needs.
ENN has also assembled a dedicated team of KM specialists
to lead the KM work with a Global Coordinator based in ENNs
London, UK sub-office. Three regional KM specialists are
based in east/southern Africa, west/central Africa and in
WFP/Tim Dirven

south Asia. The regional KM specialists bring extensive A child’s Mid Upper Arm
experience in the nutrition sector and involvement in the Circumference (MUAC) being
measured in Diffa, Niger
SUN Movement at country and regional levels, as well as

NUTRITION EXCHANGE 27
Scaling Up Nutrition

The SUN Movement

Common Results
Framework:
primary school
Understanding the CRF
WFP/Deepesh Shrestha
students receive
nutritious mid-day
meals of fortified
and lessons learned from
wheat-soya, in
Nepal
five SUN countries
This is a summary of an ENN Review of the SUN Common Results Framework (CRF)
written by Tamsin Walters, which brings together background thinking and five
examples of country level implementation in Tajikistan, Madagascar, Nepal, Niger and
Peru SUN). The full report is available at: www.ennonline.net

Madagascar, Niger and Peru are examples of countries

What is a CRF?
The 2014 SUN Movement Progress Report describes a CRF as
a single and agreed set of expected (or common) results
generated through the effective engagement of different
sectors of government and the multiple (non-government)
actors who have capacity to influence people’s nutrition. This
set of results should be based on the national goals and
targets for nutrition and reflect the ways in which different
sectors and actors can best contribute to the achievement of
these targets through their individual and collective actions.
While the ‘results’ referred to in a CRF are guided by the 1,000
days window of opportunity to improve nutrition, CRFs may
also include targets for obesity and/or overweight reduction.
• The ENN review finds that SUN Movement global
advocacy has played an important role in bringing
awareness to nutrition and gaining high-level political
commitment to move processes forward. Studies on the
cost of hunger and economic effects of malnutrition have
also proven effective in some countries. However, the role
of nutrition champions in high-level positions at national
level cannot be underestimated.
• The process of bringing stakeholders together from
across ministries, donors, United Nations (UN) agencies,
civil society, academia, the private sector and the broader
population requires a high-level convenor. Where SUN
Focal Points are based in a sectoral ministry, such as the
Ministry of Health, their ability to convene across sectors is
often compromised and plans may be skewed towards
activities of their sector.
• The case examples reveal that missed opportunities to
engage a range of actors can result in weaker plans, with
challenges arising at the implementation stage.
where there has been recognition of the need for early
consultation with the sub-national level stakeholders to
inform improved planning.
• One of the first hurdles to overcome is finding a common
ground for multiple stakeholders to engage in and invest
in. As each sector has its own operational plan and faces
competing priorities, adding nutritional indicators may be
viewed as a burden and a distraction from their core
business. The review highlights that a substantial amount
of high-level advocacy may be required to raise awareness
and understanding of nutrition as an issue that cuts across
a range of sectors.
• At the implementation stage, country experiences
advocate starting slowly, with gradual build-up of
coverage of interventions. Strong coordination teams are
required at provincial/district level to link budgets, plans,
monitoring and accountabilities.
• The development of a CRF is a process that may take years
rather than months as it requires the commitment of a
variety of different sectors and stakeholders to establish a
relevant, feasible and workable CRF.
• A key issue around funding of CRFs remains. It is unclear
how donor funds are contributing to the processes of
developing and implementing CRFs as the links between
the global level (SUN donor network) engagement and
country level appear weak.
• The author concludes by raising the question on how
CRFs resonate with fragile and conflict-afflicted states and
the particular challenges they face. Capturing experiences
from more SUN countries in such contexts would assist
learning around how the humanitarian perspective is
incorporated into CRF processes and how humanitarian
approaches are considering multi-sector engagement.

28 NUTRITION EXCHANGE
 Scaling Up Nutrition

Original article
Interview with the Dr. Hjordis Ogendo,
Head of Social Affairs and Environment, EU
Delegation in Kenya and SUN Donor Convenor
Background
Kenya was one of the first countries to sign up to the SUN Movement in November 2012 and
the European Union Delegation in Kenya agreed to be the SUN Donor Network convenor in
2013. Around this time, Hjordis arrived in Kenya as the Head of Social Affairs and
Environment and volunteered to take on the task of facilitating the SUN Donor Network.
She has been in the post for three years and will soon step down after handing over her role
to anther Donor Convenor. NEX editor Carmel Dolan interviewed Hjordis to get some
Dr. Hjordis Ogendo insights into her experiences of this role.

1. How does the Donor Network function and are there The network facilitators also meet quarterly, so I attend
specific terms of reference or guidance documents? these meetings to represent the DN. In essence, there are
When we started, nobody really knew what signing up to a large number of meetings (perhaps too many), not all of
the SUN Movement meant. We started mainly from which everyone can attend. It is also important to inform
scratch and had to think through how to go about it. I felt the DN on what has been discussed and agreed in these
that we were largely alone as a Donor Network (DN) in other meetings.
Kenya and didn’t know how it was for other DNs being
established in other countries. There was a generic terms 3. How does the Donor Network interact with
of reference developed by the SUN Movement Secretariat government – the SUN Focal Point and actors within
(based in Geneva) which we used and adapted to set out other ministries?
specific roles and responsibilities in the Kenya context. The The SUN FP is the key actor with whom the DN interacts
Kenya DN was approved and adopted in late 2014. on a regular basis. The EU has also supported the
financing of a full-time policy support position in the
2. How much work is involved for you in this role? Ministry of Health (MoH) to help the SUN FP with her
The DN-specific work requires about two days per month workload, which is considerable. In terms of other
of time and I was fortunate to be able to share this ministries, there is limited interaction between the DN and
workload with a DFID-funded consultant, who worked full these ministries at this time.
time for one and a half years supporting the DN. Without
this support, we would not have got to where we are 4. Do you think the network is better coordinated now
today. This additional support has proved vital, as in Kenya? Is there a better understanding of
facilitating the DN is on top of my main European Union duplication and gaps between donors and between
Delegation role in Kenya. donors and government now that there is this
network?
The key function of the DN is to support government
directly through the SUN Focal Point (SUN FP) in their
efforts to address malnutrition. Kenya has already School lunches are fortified with 15 essential
vitamins and minerals in Nairobi, Kenya
achieved reductions in undernutrition and is one of only a
few countries on track to achieve the World Health
Assembly targets by 2020. However, many challenges
remain as the disparities are large between various parts
of the country and in the urban, informal settlements and
there is also a growing problem with overweight and
obesity.
Every SUN network in Kenya meets quarterly so this
includes civil society, academia, UN agencies, business
and donor networks. The Government SUN FP attends the
DN meetings as well as other network meetings. As well as
SUN-related network meetings, there are technical
working group meetings on technical nutrition-related
areas. Recently, a task force was established to discuss the
WFP/Challiss McDonough

need for a multi-stakeholder platform and Common

Results Framework and to discuss advocacy on nutrition at
national and county level. In Kenya most of the nutrition-
related areas lie with the counties, so it is crucial to
advocate also at this level.

NUTRITION EXCHANGE 29
Scaling Up Nutrition
Yes, I would definitely say this is the case. There was no
donor-specific coordination on nutrition before, but now we
all know who the main donors are as well as who the smaller
donors are. We have been mapping the ‘who, what, where’
and are much better at sharing information. But I am not
saying we could not improve on this – for example, we have a
long way to go in terms of coordinated programming at
county level to avoid gaps and prevent duplication of efforts.
This is particularly pressing given that Kenya has now
devolved to 47 counties.
5. What would you say have been the main achievements
of the Donor Network?
I would highlight two great achievements. Firstly, the First
Lady of Kenya is now our Nutrition Patron, thanks to
considerable advocacy work by all the networks in Kenya. This
has had tremendous impact and still has great potential. The
First Lady is a spokeswoman and role model and therefore she
is listened to. Often in her speeches she refers to the need and
importance of a healthy and balanced diet also related to
reducing maternal and child death in the country.
As Kenya has a devolved system of power to 47 counties, we
now have the opportunity to engage the Governor’s First
Ladies in each county. People listen to them, so they are an
ideal channel to transfer powerful and simple nutrition
messages for the general population, as well as support their
role as nutrition advocates to parliamentarians.
Our second biggest achievement has been undertaking a
donor-mapping exercise for nutrition. Although we were not
given a template for this, DFID provided support for a
consultant to take on this task. We created a donor landscape
of who was doing what where and with what resources in
Kenya. As a donor community, we have found this very
useful. The report has been published and is available on the
EU Delegation’s website.
This may have been simpler for us if we had had more
guidance on how to go about such an exercise. In fact, at a
later stage, while attending a SUN Movement meeting in
Kampala, we discovered that a methodology for this type of
donor mapping was being developed and took it further by
developing a scoring system to identify nutrition-specific and
nutrition-sensitive interventions. We had not known about
this before and think it would have strengthened our work in
Water harvesting technologies have improved food
security in arid regions in north-western Kenya
WFP/Rose Ogola
30 NUTRITION EXCHANGE
Kenya. Nevertheless, I am proud to say our mapping work has
been very valuable.
6. What have been the main areas of difficulty/frustration
with the Donor Network?
One of our main difficulties is that nutrition is still seen as a
health problem. The nutrition agenda needs to open up and
go beyond the current health and food-based approaches of
supplementation and emergency nutrition interventions
focused on treatment, although these are life-saving and vital.
The European Commission has a great interest in nutrition;
therefore I had an increasing role to play to take the nutrition
agenda forward and beyond the DN. We supported meetings
between many stakeholders, not just donors, but academia
and government too to discuss the need for multi-sector
engagement and activities. It has been difficult to get key
players to see that nutrition requires a life-cycle approach in
order to tackle undernutrition as well as the growing
overweight/obesity and non-communicable diseases
challenges. What the increasing problems of overweight and
obesity mean in the context of the SUN Movement is unclear.
The perception that nutrition is an MoH problem remains a
key issue. We need to see the ministries of education,
agriculture and others equally engaged.
7. What have you learnt along the way and what advice
will you impart to the next donor convenor?
I would mention a few priorities. First, the DN needs to be
more strategic. I do not think we are there yet, mostly due to
our time constraints, as we only meet quarterly and we are
competing with other focus areas of development. We simply
don’t have time! Devolution offers an opportunity to
enhance our strategic thinking, identify county-level gaps
and avoiding duplication of our nutrition programmes. There
is scope for perhaps embarking on some joint donor
programmes at the county level. Donor networking takes
time and can’t be rushed. This is a key point and one that
needs to be appreciated more widely. To transition from a DN
that openly shares information to one that works and plans
strategically is the next stage, but this will take time and
patience.
2016 is the year of the DN and other SUN networks in Kenya
for focusing on nutrition advocacy. This is important in order
to maintain momentum for nutrition in a devolved context.
Advocacy is needed in all 47 counties.
I would encourage the new DN convenor to continue to
support the SUN FP in the country, as this is their main
partner. The SUN FP’s main role is to get the other line
ministries in the country on board and be proactive in pursuit
of SUN-related activities. In the case of Kenya, the SUN FP is
housed under the MoH, which we have seen has an
insufficient level of influence with other line ministries to be
able to get the necessary engagement. This is not a criticism,
as the SUN FP does a huge amount of work; rather, she is
limited by her position in government. Multi-sector scale-up
relies on buy-in from the highest levels and this requires a
high level, multi-stakeholder platform. This is beyond the
reach of the MoH not only in Kenya but in many other
countries. In Kenya, the SUN Movement would probably
achieve much more under the Office of the President or
under the responsibility of a line ministry that has the
convening mandate, such as ministry of planning, to get the
 Scaling Up Nutrition

intended profile. At the moment, there is a Bill on Food
Security and Nutrition with a proposed (and revitalised)
National Nutrition Council that will be based in the Office of
the President. I would like to see SUN at this level. I believe
there will be great benefits from improving the current set-up.
8. Looking back at SUN in Kenya in two to three years
time, what changes would you like to have seen?
If I were to look back in a few years time, I would very much
like to see the following achievements:
• First and foremost, I would like to see Kenya continuing to
reduce the stunting rates and other malnutrition
Original article
indicators and staying on track to achieve the WHO
targets. To achieve this, the DN needs to continue to
support the Government of Kenya;
• Stronger donor coordination and strategic thinking which
provides joint programming at the county level;
• A multi-stakeholder platform in place so that nutrition is
more prominent at higher levels and amongst the key
ministries; and
• I would like nutrition to be addressed through an
integrated approach in which other sectors play a much
more important role when we discuss nutrition in Kenya,
as well as in other countries.

Listening to SUN country actors:

A face-to-face interview with
Dr Mohamed Abdi Farrah,
Dr Mohamed Abdi
Farrah
Somalia SUN Focal Point1
Background
Somalia has been affected by civil war since 1991 and suffers from recurrent droughts, characterising it as a
complex political environment with extreme poverty, food insecurity and instability. Somalia’s malnutrition
rates are consistently among the worst in the world, with currently 13.6 per cent wasting in children under five
years of age, high levels of stunting (>26%), low levels of exclusive breastfeeding rates for infants under six
months (5%) and widespread micronutrient deficiencies. Somalia has a well-established Nutrition Cluster,
which since 2006 has grown to almost 100 active partners. This has been a forum for representing all actors,
including UN and civil society organisations, in emergency nutrition concerns over many years. More recently,
the Nutrition Cluster members have been able to engage with newly established SUN activities in Somalia.
Somalia joined the SUN Movement in 2014 and now has a national-level SUN Focal Point (SUN FP), Dr Farah,
who is based in the Office of the Prime Minister. There is also a sub-national SUN FP based in Puntland and
there are plans to expand to have more sub-national-level FPs in every state, including Somaliland. While the
SUN Movement approach has been endorsed in Somalia, an official public launch is planned in 2016 which is
seen as a way to bring people together and a chance for advocacy to further embed nutrition issues within
government.
In January 2016 Tui Swinnen, the ENN Global Knowledge Management Coordinator, met with Dr Farrah at a
Somalia Cluster meeting in Nairobi, Kenya. This presented an ideal opportunity to interview Dr Farrah to obtain
his perspectives on scaling up nutrition in such a challenging and rapidly changing environment.

1. Can you tell me about the nutrition context in
Somalia when government joined the SUN movement?
• Somalia is a context where there was no funding for
nutrition and no solid evidence/knowledge base for
nutrition due to the volatility and conflict situation.
Research in Somalia is underdeveloped and has been
haphazard. It was a difficult environment for establishing
a SUN platform.
• I recognised early on that the SUN FP, in having
responsibility for setting up the multi-stakeholder
platform (MSP), must be placed in the Prime Minister’s or
President’s office or another high post in order to ensure
the power to convene different ministries. The location of
the SUN FP within a ministry, often the Ministry of Health,
in other SUN countries has proved to be a big
challenge as this person does not have the authority
to convene other ministers or ministries, which is
critical to be able to successfully undertake nutrition-
sensitive and multi-sector planning and
programming.
2. As the Somalia context is unique, do you think
actors working to scale up nutrition in Somalia
would benefit from learning exchanges with other
countries in the Movement?
1
Special thanks go to Samson Desie, Somalia Nutrition Cluster
Coordinator, for helping arrange this interview.

NUTRITION EXCHANGE 31
Scaling Up Nutrition
A mother and child at a clinic
in Mogadishu, Somalia
WFP/Laila Ali
• There is certainly an interest in adapting sensitisation
materials for parliamentarians, which is something that
has been done elsewhere in the SUN Movement. There is
also an interest in understanding what other countries
have put in place in terms of monitoring and evaluation
frameworks for their MSP and what the expectations are.
These structures are in a nascent stage in the Somalia
context as there is no precedent to draw on.
• There is also a keenness to develop a multi-sector plan
and a Common Results Framework (CRF); therefore there
is an interest in hearing how this has unfolded in practice
in other contexts – specific practical aspects such as who
is on the MSP, how many members are viable, etc.
3. Since Somalia joined the SUN Movement in 2015,
nutrition has become a priority in Somalia with buy-in
from the highest levels of government. Can you tell me
how this shift came about?
• With security being the top priority in a country like
Somalia, the focus of leaders and government has been
on fighting insurgents, basic state-building and
reclaiming the country; it was very difficult to make the
case for the importance of investing in nutrition activities
such as stunting reduction. It was important to make the
leaders at a high level understand the importance of
nutrition and to take the right arguments to them. This
process is about educating leaders, building trust and
bringing them along. There is no quick fix – this process
takes time.
• I was involved in a key meeting in the early stages of
establishing SUN in early 2015 in Somalia and put
nutrition in perspective for the Prime Minister, with figures
on the daily and monthly deaths relating to malnutrition
in the country. The success of SUN depends on
establishing the legitimacy of the issues and getting
support from the leadership. The Prime Minister then
appointed me as SUN FP in his own cabinet, giving me the
ability to bring together different ministers and the
legitimacy to set up an MSP in the country. A challenge to
overcome is not only other pressing priorities, but also the
lack of understanding of nutrition and health at a high
level. The need for statistics as well as materials that
explain the science and fundamentals of nutrition to
someone with no background in this is essential.
• SUN is seen as a journey. It is about adaptation to unique
contexts and seeing what works for different people.
32 NUTRITION EXCHANGE
There will be a number of deep challenges to overcome in
setting up SUN structures and to scaling up nutrition.
4. What are some of the ‘deep challenges’ that need to be
overcome in Somalia?
• Coordination is an extreme challenge in Somalia, given
that the government is not fully functional and not all the
stakeholders who need to be ‘around the table’ and ‘under
one roof’ for SUN activities can physically come together
to do this. The UN actors and the donors operate out of
Kenya, while the government and local actors are based in
Mogadishu and other parts of the country. The restrictions
on international actors travelling to Somalia every time
there is a severe explosion or attack can pull the plug on
an organised event at the last minute and even the
planned SUN launch is at risk of this sudden change of
plan.
• Financial tracking is another extremely difficult issue in
this context as there is no central repository – for example
a national bureau of statistics ¬– that could do this
currently and tell us what is being invested in nutrition.
However, the nutrition strategy for health in Somalia has a
costed plan for the three regions of Somalia and includes
a micronutrient and infant and young child feeding
strategy, so financial progress is being made.
5. You have mentioned gaps in nutrition research and data
in the Somalia context. Are there any plans to fill these
gaps?
• There is currently no coordinated system in place for
knowledge management. By this I mean the collection,
evidence-building, technical assistance, documentation
and assessment of nutrition information. This is a huge
barrier for SUN activities as there is a need to be able
develop, for example, a CRF or a National Nutrition Plan
based on existing information, but this is not readily
available.
• Nutrition research for Somalia is lead by the Food Security
and Nutrition Unit (FSNAU) of FAO. UNICEF and FAO have
the best data on Somalia at present and FAO has
conducted several seasonal nutritional surveys in Somalia
with a focus on vulnerable areas. They are open to sharing
the data with government and other partners.
• SUN will be used to form a research centre for nutrition for
Somalia. There is a need to create a database of all
research, assessment and related health and nutrition
findings for the country. SUN provides new opportunities
to make use of information from neighbouring countries
in the region that would be relevant to the Somalia
context and could help fill the gap in research from
Somalia itself. We will eventually also be able to share
information with other countries.
As the Somali Government cannot oversee or control the
research and knowledge-management activities,
individual organisations conduct their own research and
produce results to inform their own programmes. There is
a need for a central repository to coordinate research in
nutrition and to set national priorities.
6. What has been the Somalia experience of setting up a
multi-stakeholder platform?
• Multi-sector engagement and structures are critical to the
success of scaling up nutrition, but cannot be rushed.
Building up new links between ministries and convincing
 Scaling Up Nutrition

new sectors to engage in nutrition simply takes time and
there are no shortcuts. It has taken me a year of meetings
and follow-up and engagement activities to bring
everyone onto the same page on nutrition for SUN in
Somalia.
• Selling nutrition to leaders and framing the issues is
critical. This must be presented in a way that resonates
with leadership and must be evidence-based. Even in
such a difficult and volatile context as Somalia, available
data and well-crafted arguments can go a long way to
making the case for nutrition. If it can be done in Somalia,
it can be done anywhere!
• I believe we need to create an ‘introductory’ package of
information, guidelines and templates for SUN. In Somalia
we have had to start from at the beginning and develop
documents and plans after joining the SUN Movement.
The SUN ‘blueprint’ must be adapted to meet the needs of
individual countries and contexts. In Somalia this means
adapting national structures to a context in which there
are three separate governments operating in the three
regions and half the network stakeholders (donor and UN)
located outside the country (in Kenya). The need for
adaptability and creative ways of setting up SUN structures
cannot be overstated.

Children attending CSO-SUN

Global Day of Action

Role of communication
and advocacy in scaling
up nutrition: lessons
and plans from the
Zambian experience
Field Article FEX51, p7
E Phiri, Zambia

By Eneya Phiri, Head of Advocacy and Communications

at Zambia Civila Society SUN Nutrition Alliance

Background increase coverage of effective and integrated nutrition

In children under five years of age, the Republic Zambia has
high levels of stunting (40%) and wasting (6%), and high
levels of micronutrient malnutrition. Over the years, there has
also been an increase in overweight/obesity, affecting an
estimated 23% of women.
Zambia joined the SUN Movement in 2010 and the
government is determined to address malnutrition from a
multi-sector and multi-stakeholder perspective. The SUN
framework in Zambia is designed so that the National Food
and Nutrition Commission, the statutory body charged with
responsibility to coordinate action on nutrition in Zambia
under the Ministry of Health, is at the centre of efforts to
scale up nutrition. This houses the SUN Focal Point (SUN FP).
The SUN FP coordinates action across other SUN networks,
including academia, UN and business and civil society
networks. As a result, for the first time, the government, civil
society, the private sector and cooperating partners are all
collectively engaged in fighting malnutrition. This article
provides an overview of the role of communication and
advocacy contributions of the Civil Society SUN (CS-SUN)
Alliance in Zambia.
Established in 2012, the CS-SUN Alliance is a movement of
civil society organisations working together to raise the
profile of nutrition on the national development agenda to
programmes. This requires increased networking among key
stakeholders across sectors, advocating for resource
commitments to nutrition, and holding those in office to
account. CS-SUN public awareness-raising work has had
considerable success. For example, the CS-SUN successfully
ran a campaign that culminated in the review of the National
Food and Nutrition Act of 1967; has supported Zambian
political parties to include nutrition messages in the
presidential campaigns; conducts national budget analysis
and tracking for nutrition sector spending since; and has
trained the media on nutrition reporting.
The lessons learnt so far include learning to package
messaging properly so that nutrition concepts are broken
down into simple, meaningful language that can be widely
understood. Quick follow-up action is required when
awareness-raising activities take place because, when
communities are made aware, they start to demand better
nutrition programming. Learning to work with
parliamentarians as a specific target group has also brought
lessons on how to bring the needs of their constituents to
their attention. Finally, lessons also include the realisation
that, by belonging to a global network of nutrition actors, the
SUN Movement makes for easy access to information to
facilitate cross-learning. For example, Zambia has been
paired with Malawi to benefit from regional learning.

NUTRITION EXCHANGE 33
Scaling Up Nutrition
SUN Experiences: Lessons from Pakistan
Field article, FEX51 p10
Muhammad Aslam Shaheen is SUN Focal Point in Pakistan.
Dr. Ali Ahmad Khan is Programme Officer for the SUN Secretariat,
Ministry of Planning, Development and Reform, Pakistan.
Background
In Pakistan, the nutritional status of children under five years
of age is extremely poor. At a national level almost 40% are
underweight. Over half the children are affected by stunting
and about 9% by wasting. There are significant provincial
variations in these rates in Pakistan and the prevalence of
stunting appears to be associated with the overall level of
development of the provinces, being lowest in Punjab and
highest in Balochistan Province.
The Islamic Republic of Pakistan joined the SUN Movement in
April 2013. The Chief of Nutrition is the SUN Focal Point and
deals with technical and operational matters related to the
Movement. His efforts are in line with the Pakistan Vision
2025 and guidance is provided by the Members, Secretary
and Minister for the Ministry of Planning Development and
Reform. The SUN Movement in Pakistan is currently working
under the direction of the Planning Commission of Pakistan,
the government body that regulates almost all programmes
and proposals related to federal and provincial departments.
A SUN Core Group (or National Nutrition Committee) (NNC)
has been formed which is the equivalent to the SUN multi-
stakeholder platform and consists of 15 key members of
development partners and ministries who steer the process
forward in the country. In addition, six specific networks
(Government, UN, Donor, Civil Society Alliance, Business
Network and Academia and Research) have been formed for
streamlined efforts to scale up nutrition in the country.
SUN Movement experiences in Indonesia
Field article, FEX 51 p 16
Nina Sardjunani is SUN Lead Group member, and Endang L. Achadi,
Professsor in the Faculty of Public Health, University of Indonesia.
Background
Undernutrition rates in Indonesia are high with stunting and
wasting affecting 37% and 12% of children under five
respectively. There is large regional variation in stunting
prevalence, with rates as high as 58% in some parts of the
country. Overweight/obesity is also increasingly becoming a
significant concern, with 14% of children under five, 20% of
children aged five to 12 years, and 33% of women over 18
classified as overweight/obese.
The Republic of Indonesia joined the SUN Movement in 2011 at
a time when the Ministry of Health and the Coordinating
Ministry of People’s Welfare began the ‘First 1,000 Days of Life
Movement’ and Bappenas (the Ministry of National
Development Planning) decided to formulate a SUN Policy
34 NUTRITION EXCHANGE
SUN Focal Points have been appointed in four devolved
provinces to coordinate their efforts for scaling up nutrition as,
since devolution, every province is autonomous in planning
and setting its priorities. After joining the SUN Movement,
nutrition-specific and nutrition-sensitive programme budget
analysis was performed for the first time. Results were
presented in the SUN Movement Financial Tracking Workshop
held in Asia in early 2015. For 2015-16, there is specific budget
allocation for Nutrition and the Sustainable Development
Goals (SDGs), an additional tranche of funding.
The added value of the SUN Movement in Pakistan is the
increased coordination between the donors, UN agencies
and other development partners with government.
Government’s ability to scale up nutrition in the country is
increased and 2015-16 is the first year that there has been
direct allocations of funds by government for nutrition-
specific and nutrition-sensitive programming.
The authors conclude that Pakistan has made significant
strides towards scaling up nutrition in Pakistan: nutrition is
seen as a multi-sector challenge and efforts have been made
to involve all relevant sectors. The aim has been to plan
multi-sectorally but to implement sectorally, then evaluate
multi-sectorally. It is too early to say if and how this multi-
sector approach is working as the process is slow and
requires patience and teamwork from all stakeholders.
Continued advocacy and monitoring and evaluations will be
required to ensure that these efforts are productive.
Framework. This article describes how political and policy
commitment was obtained from relevant ministries in Indonesia
and led to a Presidential Decree approved and launched in
October 2013. The SUN principles were included in the five-year
National Medium Term Development Plans for 2015-2019, and
the National Action Plan on Food and Nutrition was aligned to
the SUN Common Results Framework (CRF) by engaging 13
ministries and two national board/agencies in the process so
that nutrition was addressed by multiple stakeholders. The
Presidential Decree also mandated the establishment of a
coordinating mechanism for a multi-stakeholder, high-level Task
Force led by the Ministry of People’s Welfare.
Nutrition-sensitive programmes are in place. These include
the Ministry of Public Works and Public Housing programme

to build water and sanitation facilities, the Ministry of
Industry food fortification programmes, and the Ministry of
Trade stabilisation of food prices. Both nutrition-specific and
nutrition-sensitive interventions have been costed through
the budget allocation for each programme and the
integration of this into the National Action Plan.
Stakeholder Networks of the Indonesia SUN Movement have
also been established under the SUN technical team and
include the UN Country Network, the SUN Business Network,
the SUN Civil Society Alliance, and the Donor and UN
Country Network on Nutrition.
Six Working Groups (Campaign, Advocacy, Training, Planning
and Budgeting, Partnership and Environmental Risk Factor
Study) have been established and are supported by an
Expert Team. Each Working Group convenes meetings to
discuss their strategies and programmes. The Networks
Original article
Nakuru media training - Group Work
Nutrition advocacy in Kenya’s
newly devolved government system
Titus Mung’ou was the Advocacy and Communications Manager at Action
Against Hunger (ACF) at the time of writing.
Jacob Korir is the Head of Health and Nutrition and Health Department at
ACF Kenya Mission. He is the current Chair of the SUN CSA
Background
The Kenya Demographic Health Survey (KDHS) 2014
indicates significant progress in nutrition in Kenya over
the past five years. Stunting levels decreased from 35% to
26%; wasting rates declined from 7% to 4%; and the
proportion of underweight children dropped from 16% to
11%. The 2015 Global Nutrition Report declared Kenya the
only country in the world classified as being on course to
meet all five maternal and child nutrition targets1. Despite
the progress, however, malnutrition continues to pose a
risk to the lives and livelihoods of a significant proportion
of the population.
NUTRITION EXCHANGE
Scaling Up Nutrition
reflect the SUN approach: government, UN, donor agencies
and international agencies are grouped as one network; civil
society organisations comprised of academia, professional
organisations and NGOs are grouped as a second; and
business as a third network.
Some of the implementation challenges linked to the current
context include limitations in food availability and diversity
due to reduced domestic food production, poor food access
due to the decline in purchasing power caused by poverty
and unstable food prices, and Indonesia’s double burden of
malnutrition. The authors also remark on how Indonesia’s
recognition of its current double burden of malnutrition
situation has led to a multi-stakeholder approach and
considerable buy in at presidential level, but also that
significant challenges remain for increased decentralisation
at district level to implement the National Plans.
Since 2013, stakeholders in Kenya’s nutrition sector have
been realigning programmes to address the devolution of
political, economic and decision-making power to the 47
newly created counties2. Under the new constitution, the
health sector – including nutrition – is fully devolved to
county-level governments, along with water and some
treasury services. Sensitisation of nutrition sector actors
on the structures and operations of governments is
1
Stunting, overweight, wasting, exclusive breastfeeding and anaemia (the
sixth, low birth weight is not included in the GNR report rating)
2
Devolution of Health Care Services in Kenya. Lessons Learnt from Other
Countries, KPMG 2013, p3, www.kpmgafrica.com.
35
Scaling Up Nutrition

therefore essential for the successful implementation of

Figure 1 Stunting prevalence 2014 in Kenya by county nutrition programmes in these counties. This article reflects on
some of the progress to date.
Height for Age – (Stunting) National and county-level responsibilities in the
health sector3
The Kenya Health Policy 2014-2030 proposes the formation of
county health departments whose role will be to create and
provide an enabling institutional and management structure
responsible for “coordinating and managing the delivery of
healthcare mandates and services at the county level.” The
county health management teams provide “professional and
technical management structures” to coordinate the delivery of
services through health facilities in each county.
However, allocation of funds remains poor. A World Bank study
notes that Kenya, as a signatory to the 2001 Abuja Declaration,
“committed to allocating at least 15 percent of its national
budget to health. Not only is Kenya spending a relatively low
amount (7% in 2013) as a percentage of GDP on healthcare, but
the allocation of funds to public facilities has been uneven.”4
Primary care facilities and community health play a significant
Legend
role as the first point of contact in the provision of healthcare
Province boundry
services.
Height for Age (%)
< 20 (Acceptable In recent years, the nutrition spotlight has been on county
20 – 29 (Poor) level. According to the KDHS 2014, more than ten counties are
30 – 39 (Serious) grappling with deteriorating malnutrition levels5.
=> 40 (Critical)
Waterbodies Source: DHS – 2014 With fewer than 15 out of 47 counties in Kenya making positive
progress in scaling up nutrition, there is a huge task to
consolidate efforts in the rest of the counties. Nutrition
stakeholders have to overcome limited resources, low
Figure 2 Wasting prevalence 2014 in Kenya by county
awareness of the importance of good nutrition, inadequate
policies and weak coordination mechanisms across sectors in
Weight for Height – (Wasting) order to reverse the malnutrition trends.

The SUN Movement networks, through the leadership of the

government-appointed SUN Focal Point in the Ministry of
Health Nutrition and Dietetics Unit, have been developing
strategies and guidelines. This includes the Advocacy,
Communication and Social Mobilization (ACSM) Strategy,
which aims to:
• Mobilise multi-stakeholders to support scaling up
nutrition;
• Identify and build the capacity of county nutrition
champions;
• Support and strengthen coordination of health and
nutrition programmes;
• Lobby county governments to increase the number of
nutritionists;
• Support the review of County Integrated Development
Plans (CIDPs) to improve the status of nutrition;
Legend • Advocate to county governments to increase nutrition
Province boundry budgets;
Weight for Height (%) • Work with media to sensitise communities to scale up
< 5 (Acceptable) nutrition; and
5.1 – 10 (Poor) • Conduct county media training on reporting nutrition
10 – 15 (Serious) issues.
> 15 (Critical)
Waterbodies Source: DHS – 2014 The SUN Civil Society Alliance (SUN CSA) has mobilised 44 civil
society organisations (CSOs) at national level and 30 others at
county level. With funding from the SUN Multi-Partner Trust
3
Source: Constitution of Kenya, 2010. Fourth Schedule.
Fund, the network has established eight county CSA sub-
4
Regional Comparison of Total Health Budget as a Percentage of GDP 2010- national/county chapters with members such as women and
2011 p3. youth groups and human rights and consumer associations not
5
Kenya Demographic Health Survey 2014 Key Indicators Report p35.
www.knbs.or.ke/index.php?option=com_content&view=article&id=308: traditionally seen as part of the nutrition sector. In 2015, SUN
2014-kenya-demographic-and-health-survey-2014-) CSA conducted two SUN sensitisation workshops for

36 NUTRITION EXCHANGE

representatives of the business community in West Pokot
and Isiolo counties which led to the formation of the public-
private sector partnership for nutrition in West Pokot County,
a major milestone for SUN at the grassroots level.
Another achievement in the 2015/16 financial year in some
counties was successful advocacy to county governments to
recruit more nutritionists. West Pokot County, which has the
highest prevalence of stunting in Kenya (45.9%)6, now has
one nutritionist per 27,000 population, compared to one per
82,000 last year. The nutritionists help ensure access to
optimal, high-impact nutrition services. They are government
employees on government payroll.
County nutrition champions
A key task of SUN networks has been to identify nutrition
champions at national and county levels to drive the
nutrition agenda. Kenya’s First Lady became Nutrition Patron
in March 2015. At least seven county First Ladies (wives of
governors), politicians and celebrities have been identified
and have accepted the role of nutrition champions. First Lady
Margaret Kenyatta’s Beyond Zero Campaign has integrated
nutrition issues in its maternity mobile clinic initiative that is
targeting counties, especially those grappling with access to
quality health services. On 16 December 2015, SUN CSA held
a county nutrition champions workshop7 in which
participants came up with four key recommendations:
• To build capacity of nutrition champions to promote
nutrition through the media;
• To develop nutrition messages for nutrition champions
translated to their mother tongue;
• To complete county Nutrition Action Plans to enable the
champions to push for specific budget lines in county
budgets;
• To organise a two-day nutrition advocacy training for
county nutrition champions, to include over 20 First
Ladies.
Way forward and next steps
Sensitisation of county-level stakeholders on SUN, the ACSM
strategy, development of criteria for identification of
nutrition champions, guidelines for engagement with
parliamentarians, formation of new county SUN CSA chapters
and coordination of nutrition advocacy trainings are among
key activities earmarked by the SUN networks this year. The
goal is to mobilise diverse stakeholders and leaders to
prioritise nutrition, while building capacity of nutrition actors
to position nutrition as a development agenda.
While the establishment of a SUN Multi-Stakeholder Platform
at the national level seeks to position nutrition coordination
Participants after SUN CSA Nutrition
Advocacy Workshop in Kajiado
NUTRITION EXCHANGE
Scaling Up Nutrition
in the Office of the President, the quest by SUN networks is to
position nutrition in the Office of the County Governors. This
has partly been achieved following the identification and
sensitisation of nutrition champions from five counties in
December 2015.
Training of county-level journalists on nutrition reporting,
support to journalists to cover nutrition programmes, and
sensitisation of nutrition technical staff to work with the
media have been bolstered in at least six counties supported
by SUN CSA. The training of more than 45 journalists, mostly
from the counties, on nutrition reporting is expected to
transform public views and perception on scaling up
nutrition.
Documentation of malnutrition situation, best practices and
research findings will be prioritised by SUN networks to
improve evidence-based advocacy. Through joint field trips
to nutrition projects in the counties by technical officers, key
decision-makers and journalists, more awareness of the real
situation is expected to lead to increased allocation of
resources. Another important step will be to capture and
upload data onto the website of the Ministry of Health
Nutrition and Dietetics Unit,8 which has created pages for
counties. The first SUN CSA best practice booklets covering
national and county advocacy activities were published in
2015.
Conclusion
As Kenya enters a new chapter in health and nutrition, the
nutrition landscape is being aligned steadily following the
establishment of SUN networks, sensitisation of key
stakeholders on nutrition issues, identification of nutrition
champions and integration of nutrition programmes into the
devolved government system.
Devolution to the county governments is expected to
strengthen the quest to tackle malnutrition at community
level. In the past two years, SUN networks and stakeholders
at the national level have been supporting counties to
develop their CIDPs, cost their county Nutrition Action Plans,
and lobby for the creation of clear budget lines for nutrition
programmes. Despite the high levels of undernutrition in
some counties, there is light at the end of the tunnel thanks
to the progress Kenya is making in being on track to meet
World Health Assembly nutrition targets.
6 Kenya Demographic Health Survey 2014. dhsprogram.com/pubs/pdf/FR308/
FR308.pdf
7 County Nutrition Champions Workshop Report 2015. Available at
mptf.undp.org/document/download/14540
8 www.nutritionhealth.or.kenya
37
 News and events

WFP/David Longstreath
News and events Sustainable Development Goal 2:
End hunger, achieve food security and improved
nutrition, and promote sustainable agriculture1
Agreed by all UN member states, Transforming Our World: 2030 Agenda for Sustainable
Development, consists of a Declaration, 17 Global Goals and 169 targets, a section on means of
implementation and renewed global partnership, and a framework for review and follow-up.

Within the 2030 Agenda, the UN member states have committed to comprehensive, integrated
and universal transformations which include ending hunger and malnutrition once and for all by
2030. This ambition is captured in Global Goal 2, which includes achievement of food security,
improved nutrition and sustainable agriculture as part of a comprehensive set of actions.

S Kamal/Tdh, Bangladesh, 2013

The following targets are associated with the goal:
2.1 By 2030 end hunger and ensure access by all people, in particular the poor and people in
vulnerable situations including infants, to safe, nutritious and sufficient food all year round.
2.2 By 2030 end all forms of malnutrition, including achieving by 2025 the internationally
agreed targets on stunting and wasting in children under five years of age, and address the
nutritional needs of adolescent girls, pregnant and lactating women, and older persons.
2.3 By 2030 double the agricultural productivity and the incomes of small-scale food producers,
particularly women, indigenous peoples, family farmers, pastoralists and fishers, including
through secure and equal access to land, other productive resources and inputs, knowledge,
financial services, markets, and opportunities for value addition and non-farm employment.
2.4 By 2030 ensure sustainable food production systems and implement resilient agricultural
practices that increase productivity and production, that help maintain ecosystems, that
strengthen capacity for adaptation to climate change, extreme weather, drought, flooding
and other disasters, and that progressively improve land and soil quality.
2.5 By 2020 maintain genetic diversity of seeds, cultivated plants, farmed and domesticated
animals and their related wild species, including through soundly managed and diversified
seed and plant banks at national, regional and international levels, and ensure access to and

F Struzik/Image of Dignity, Bangladesh, 2012

fair and equitable sharing of benefits arising from the utilization of genetic resources and
associated traditional knowledge as internationally agreed.
2.6 Increase investment, including through enhanced international cooperation, in rural
infrastructure, agricultural research and extension services, technology development, and
plant and livestock gene banks to enhance agricultural productive capacity in developing
countries, in particular in least developed countries.
2.7 Correct and prevent trade restrictions and distortions in world agricultural markets
including by the parallel elimination of all forms of agricultural export subsidies and all
export measures with equivalent effect, in accordance with the mandate of the Doha
Development Round.
2.8 Adopt measures to ensure the proper functioning of food commodity markets and their
derivatives, and facilitate timely access to market information, including on food reserves, in
order to help limit extreme food price volatility.

Dr. David Nabarro, who previously coordinated the SUN Movement, has been appointed Special
Adviser on the 2030 Agenda for Sustainable Development to work with member states and other
relevant stakeholders to galvanise action on implementation of the Agenda. He will bring his
considerable knowledge of the SUN Movement to the nutrition-related SDGs. At least 12 of the
WaterAid/ Panos/ Adam Patterson

17 Global Goals contain indicators that are highly relevant for nutrition, reflecting the centrality
of nutrition for instigating comprehensive change.

Improved nutrition is the platform for progress in health, education, employment, female
empowerment, poverty reduction and the mitigation of greenhouse gas emissions. In turn,
water, sanitation and hygiene, education, food systems, climate change, social protection and
agriculture all have an important impact on nutrition outcomes.

While the ambition of the nutrition community is grounded in Goal 2, a nutrition revolution is
needed to ensure the full potential of all goals across the 2030 Agenda to bring lasting benefits
to everyone, everywhere.

To find out more visit www.un.org/sustainabledevelopment/hunger/

1
We thank Florence Lesbannes of the SUN Movement Secretariat for help in writing this piece.

38 NUTRITION EXCHANGE
 News and events

WFP/Agron Dragaj
The Second World Breastfeeding Conference, 11-14 December 2016,
Johannesburg
The International Baby Food Action Network in partnership with the Government of the Republic of
South Africa, will host the Second World Breastfeeding Conference in Johannesburg, South Africa.

The conference will call for committed action and provide a platform for breastfeeding advocates,
governments, scientists, civil society organisations, UN agencies, international organisations,
research institutions, public interest groups and other stakeholders to discuss and share
experiences. It will provide an opportunity to review the global investment promises for maternal
and infant and young child nutrition.

The conference will address breastfeeding in a human rights framework and will raise awareness on
progress to date in improving breastfeeding rates, which has occurred at different speeds in many

F Struzik/Image of Dignity, Bangladesh, 2012

countries. It will raise awareness of the challenges in the promotion, protection and support of
breastfeeding and other IYCF interventions due to funding, structural, policy and political
environment.
Read more at www.worldbreastfeedingconference.org

eLENA mobile phone application now available!

The WHO e-Library of Evidence for Nutrition Actions (eLENA) is an online library of evidence-
informed guidance for nutrition interventions. It is a single point of reference for the latest
nutrition guidelines, recommendations and related information, including supporting materials.

In recognition that access to eLENA content in settings without regular or reliable internet access is
problematic, WHO has developed an eLENA mobile phone application, eLENAmobile, which
delivers much of the content of eLENA to smartphones and can be accessed anywhere – no

R. Aryeetey, Ghana, 2014

internet connection is required.

eLENA aims to help countries successfully implement and scale up nutrition interventions by
informing as well as guiding policy development and programme design. eLENA is available in all
six official UN languages. Nutrition interventions are listed in alphabetical order for easy access.
Read more at www.who.int/elena/en/

General Assembly proclaims the Decade of Action on Nutrition

The Decade of Action on Nutrition is a commitment of Member States to undertake ten years of
sustained and coherent implementation of policies and programmes. It will increase the visibility
of nutrition action at the highest level, ensure coordination, strengthen multi-sectoral
collaboration and measure progress towards food and nutrition security for all. The resolution
recognises the need to eradicate hunger and prevent all forms of malnutrition worldwide.
©IFPRI/Gert-Jan Stads

159 million children under five years of age are stunted.

Approximately 50 million children under five are wasted;
over two billion people suffer from micronutrient
deficiencies and 1.9 billion are affected by overweight,
with over 600 million of them obese.

The resolution calls upon FAO and WHO to lead the implementation of the Decade of Action on
Nutrition in collaboration with the World Food Programme (WFP), the International Fund for
Agricultural Development (IFAD) and UNICEF, involving coordination mechanisms such as the
United Nations System Standing Committee on Nutrition (UNSCN) and multi-stakeholder
platforms such as the Committee on World Food Security
To find out more visit http://www.ipcinfo.org/

NUTRITION EXCHANGE 39
 English

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